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UNITED STATES OF AMERICA. 



1 



OPEBA MESTOKA 



A COLLECTION" OF 



ESSAYS, ARTICLES, LECTURES AND ADDRESSES 
FROM 1866 TO 1882 INCLUSIVE 



v > 
BY 

EDWARD C«*SEGUIN, M.D. 

CLINICAL, PROFESSOR OF DISEASES OF THE MIND AND NERVOUS SYSTEM IX 
THE COLLEGE OF PHYSICIANS AND SURGEONS, NEW YORK, ETC. 




" XEW YOEK 

GL P. PUTNAM'S SONS 

27 and 29 West 23d Street 

London : 25 Henrietta Street, Covent Garden: 

1884 



Copyright, 1883, 
By G. P. PUTNAM'S SONS. 



1 






TO .MY FRIEND 

AND 

MASTEK IN THE CLINICAL ART, 

PEOFESSOE WILLIAM H. DEAPEE, M.D„ 

THIS VOLUME IS AFFECTIONATELY INSCRIBED. 

E. C. Seguln. 



PREFACE. 



An apparently unlimited interruption having taken place in 
my professional life, the idea occurred of reprinting my various 
medical contributions for private circulation. 

Yielding to the advice of several friends, I have consented to 
the issue of a larger edition for regular sale. 

In offering these articles, etc., to the profession I need make 
no apology, because I do it in the same spirit that led me to pub- 
lish them separately. I have, I hope, a due appreciation of the 
faults in some of the essays, of fche shortcomings of many others, 
and of the fact that some of them possess only an historical in- 
terest. The redeeming feature in the collection will perhaps be 
the series of observed facts, faithfully recorded, which may prove 
of some use to the practical physician as well as to the pathol- 
ogist. 

"Without an editor this volume could not have appeared. 
I desire to thank my friend Dr. Amidon for the patience and 
accuracy he has shown in the performance of his task, which 
involved among other things the reduction of all measures to the 
metric and centigrade scales, and the verification of every refer- 
ence. 

E. C. JSeguin. 

Zurich, Switzerland, August, 1883. 



CONTENTS 



PAGE 

The Use of the Thermometer in Clinical Medicine 1 

On the Subcutaneous Use of Sulphate of Quinine in Cases of Malarial Neu- 
ralgia 10 

On Treatment of Malarial Fevers by the Subcutaneous Use of the Sulphate of 

Quinine 15 

The Hypodermic Injection of Quinine 22 

A Statement of the Aphasia Question, together with a Eeport of Fifty Cases... 27 

Cases in which Aphasia occurred with Right Hemiplegia 44 

Cases in which Aphasia occurred with Left Hemiplegia 52 

Cases in which Aphasia occurred with Double Hemiplegia 52 

Cases in which Aphasia occurred without Hemiplegia 53 

Case of Trichinosis 55 

A Case of Acute Ocular (Edema — cause unknown 56 

Cas de Lesion probable de Ja moitie laterale droite dc la moelle epiniere, dans 
la region cervicale inferieure, ayant prod nit de l'anesthesie d'un cote et 

de la paralysie de l'autre * 57 

Autopsy of a Case of Mania G2 

Contributions to the Pathological Anatomy of the Nervous System 72 

Case of General Paresis of the Insane 76 

Infantile Spinal Paralysis 84 

A Case of Traumatic Brachial Neuralgia treated by Excision of the Cords 

which go to form the Brachial Plexus, 97 

On the Inhibitory Arrest of the Act of Sneezing, and Its Therapeutical Appli- 
cations 118 

Description of a Peculiar Paraplegiform Affection. (Tetanoid Paraplegia.). • 127 

Lecture upon the General Therapeutics of the Nervous System 189 

An Outline of the Physiology of the Nervous System 164 

On Hysterical Symptoms in Organic Nervous Affections 180 

Syphilitic and Simple Pachymeningitis 195 

A Clinical Contribution to the Study of Post-Paralytic Chorea 197 

Contribution to the Study of Localized Cerebral Lesions 202 

Cases in which a more or less limited Cerebral Lesion produced Aphasia. 202 

Cases in which a limited Cerebral Lesion caused Paralysis 214 

Cases in which localized Cerebral Lesions gave rise to Localized Con- 
vulsions or Spasm 215 

The Abuse and Use of Bromides 226 

A Contribution to the Therapeutics of Migraine 242 

Bulbar Paralysis. (Atypical Case of Labio-Glosso Pharyngeal Paralysis) . 249 



vm • CONTENTS. 

PAGE 

Localized Basal Meningitis in Children 251 

A Clinical and Therapeutical Contribution to our Knowledge of Cervical Par- 
aplegia 256 

A Contribution to the Pathological Anatomy of Disseminated Cerebro-Spinal 

Sclerosis 264 

A Clinical Lecture on Syphilitic Cerebral Lesions 276 

Lectures on the Localization of Spinal and Cerebral Diseases 283 

Lecture I. — Summary ; Introductory Remarks 283 

Historical Considerations 287 

Lecture II. — Synopsis ; Systematic Lesions of the Spinal Cord ; Lesions 

in the iEsthesodic System ; Lesions in the Kinesodic System 293 

Lecture III. — 1. Systematic Diseases of the Spinal Cord continued ; 

Lesions in the Kinesodic System 300 

2. Non-Systematic or Focal Lesions of the Spinal Cord ; Lesions at 

different heights in the Organ 304 

Lecture IV. — Non-Systematic or Focal Lesions of the Spinal Cord con- 
tinued ; Lesions involving one lateral half of the Spinal Cord, in its 

Lower and Upper Regions ; Diagnosis of Spinal Hemiplegia 309 

Anatomy and Diseases of the Medulla Oblongata 311 

Lecture V.— Summary 318 

Lesions of the Basis Cerebri 318 

Physiological Anatomy 319 

Symptoms of Lesions of the Basis Cerebri 322 

Lesions of the Pons Varolii 322 

Lesions of the Crura Cerebri 324 

Lesions situated at the Base of the Brain anteriorly to the Crura 325 

Lecture VI. — Summary 329 

Lesions of the Great Ganglia at the Base of the Brain, and of the 

white substance of the Hemisphere 329 

Lesions of the Basal Organs 333 

Lesions of the Internal Capsule 333 

Lesions of the Cerebellum 335 

Lecture VII. — Summary : Anatomy and Lesions of the Cortex of the 
Brain ; the Chief Cortical Motor Centres, and Broca's Speech-Cen- 
tre ; Localized Lesions of the Cortex Cerebri ; Diffused Lesions of 

the same 337 

Lecture VIII.— Surgical Aspects of the question of Cerebral Localiza- 
tion ; Cranio-Cerebral Topography and its Utilization in Diagnosis 

and for Operative Procedures 348 

The Diagnosis of Progressive Locomotor Ataxia 353 

Report on Aconitia in the Treatment of Trigeminal Neuralgia 367 

A Contribution to the Medicinal Treatment of Chronic Trigeminal Neuralgia. 375 
Dermatitis Produced by Three Preparations of Opium in the Same Subject. . 380 

Myelitis of the Anterior Horns of Traumatic Origin 381 

The Present Aspect of the Question of Tetanoid Paraplegia 383 

The Use of the Actual Cautery in Medicine 393 

Traumatic Pedal Neuralgia of One Year's Standing Rapidly Cured by the 

Actual Platinum Cautery 401 

Case of Desquamation of the Kidneys during the Administration of Mercury 
and Iodide of Potassium 403 



COXTFXTS. ix 

PAGE 

" Folie A Deux " 405 

Case of Hemiplegia with First Symptoms in Foot, and a Limited Cortical Lesion 407 

Case of Slovr Pulse and Epileptiform Convulsions 409 

A Contribution to the Pathology of Acute Central Myelitis 412 

Paraplegia in Syphilitic Subjects 413 

A Case of Movable Kidneys ; Remarkable Voluntary Control Over These 

Organs , 41 5 

Case of Cerebral Hemorrhagic Pachymeningitis 416 

The Intra-Buccal Method of Faradizing the Lower Facial Muscles 419 

On the Coincidence of Optic Xeuritis and Subacute Transverse Myelitis 421 

A Case of Mysophobia 429 

On Occipital Headache as a Sympton of Uraemia 432 

The Localization of Diseases in the Spinal Cord 436 

A Case of Abscess of the Left Frontal Lobe of the Cerebrum, with Special 

Reference to Localization 452 

On the Early Diagnosis of Some Organic Diseases of the Xervous System 457 

Report on the U"se of Hyoscyamia as an Hypnotic and Depresso-Motor 472 

Historical 472 

Clinical Experience with Hyoscyamia as an Hypnotic 477 

Cases Reported by Dr. A. B. Ball 480 

A Case of Delirum Tremens, by Dr. F. P. Kinnicutt 482 

A Case Contributed by Dr. Andrew H. Smith 482 

Case of Morbid Dreams, by Dr. E. C. Seguin 482 

Hyoscyamia as a Depresso-Motor 484 

do in Choreiform Affections 488 

The Physiological Effect of Aconitia in Posterior Spinal Sclerosis : Can It 

Become an Aid in Differential Diagnosis ? 492 

A Case of Diphtheritic Ataxia and Paralysis from Anal Diphtheria — Cure 493 

A Second Contribution to the Study of Localized Cerebral Lesions 495 

Expressions of Symbols, by Dr. A. B. Ball 511 

Comprehension of Symbols, do do 514 

Dr. Seguin's Report of the Autopsy 518 

Concluding Observations by Dr. Seguin 520 

On the Use of a Feebly Alkaline Water as a Vehicle for the Administration 

of the Iodide and Bromide of Potassium, etc 529 

History of Attempts Made to Cure Three Cases of Chronic Trigeminal Xeu- 

ralgia 534 

Importance of the Early Recognition of Epilepsy 540 

On the Methods of Diagnosis in Diseases of the Xervous System 558 

The Efficacy of Iodide of Potassium in Xon-Syphilitic Organic Diseases of the 

Central Xervous System 579 

Ideas of Different Authors bearing on the Subject 592 

On the Efficient Dosage of Certain Remedies Used in the Treatment of Xervous 

Diseases. (I.) 594 

On the Efficient Dosage of Certain Remedies Used in the Treatment of Xervous 

Diseases. (II.) 599 

Crystallized Aconitia of Duquesnel 599 

Phosphorus and Phosphide of Zinc 602 

Crystallized Nitrate of Silver 605 

Case of Injury to the Motor Area of the Brain, with Exhibition of the Patient. 608 



X CONTEXTS. 

PAGE 

Remarks on the Frequency of Headache and Choked Disc with Tumor of the 

Brain 609 

Vertebral Cancer and Paraplegia 612 

Myelitis Following Acute Arsenical Poisoning by Paris or Schweinfurth 

Green 616 

On a Peculiar Cutaneous Lesion (Ulcus Elevatum) Occurring During the Use 

of Bromide of Potassium 629 

A Case Illustrating the Coincidence of Diseases : Cervico-Brachial Neuralgia 

and Aneurism of the Innominate Artery 636 

Aneurism of the Cceliac Axis 639 

Hysterical Convulsions and Hemi- Anaesthesia in an Adult Male : Cured by 

Metallo -Therapy (Gold) 641 

Two Cases of Glycosuria : One True and One Simulated 644 

Note on Cranio-Cerebral Topography. (Illustrated) 647 

The Treatment of Mild Cases of Melancholia at home 655 

The Cultivation of Specialties in Medicine 672 



Opera Mixora, 



THE USE OF THE THERMOMETER IN CLINICAL 

MEDICDsE.- 

Believing that the matter may prove of interest, and that 
the attention of practitioners may thns be called to a means of 
diagnosis and prognosis not second in importance to any single 
one hitherto employed, the following cases of pneumonia, ob- 
served and treated in the Xew York Hospital during the month 
of January, 1866, are given as illustrative of the amplication of 
thermometry in disease ; together with an abstract of the highly 
interesting and elaborate paper of Dr. L. Thomas, of Leipzig, 
on the thermal phenomena of pneumonia. (" "Leber die Tern- 
peratur Yerhaltnisse bei crouposer Pneumonie," Archiv der 
Heilkunde ; Bd. Y, S. 30-360 

The cases are accompanied by a diagram, facsimile of the 
tables of "Vital Signs " used at the bedside to make the daily 
record of temperature, pulse-beats and respirations. This one 
only differs from ours in that on it are represented the curves 
for three cases, whereas usually but one case is jDut upon a 
table. Xo further explanation of the diagram is necessary, ex- 
cept to state that the heat is registered in decimal parts of de- 
grees ; the pulse and respirations, of course, by whole numbers. 

*From the Chicago Hedical Journal, Itfay, 1866, — This article and the observa- 
tions leading to it form the starting point of Medical Thermometry in the United 
States. 

The annexed table for recording vital signs was designed by Dr. William H. 
Draper and Dr. Seguin conjointly. At the time Dr. Segnin was senior assistant 
in the medical department of the Hospital, and during the remainder of his service 
(until Aug. 1, 186?) gave a great deal of his time to the thorough practice of ther- 
mometry. It then became part of the hospital routine, and has so continued. It 
may be safely claimed that medical thermometry spread from this institution as a 
focus.— R. W. A. 
1 



2 THERMOMETER IN CLINICAL MEDICINE. 

Two observations are found in each daily column, one in the 
morning made at 9.10 a.m., one for the latter part of the day 
made at 4.15 p.m. 

For want of space the cases are much abbreviated ; the phys- 
ical examinations being nearly omitted. This may be justified 
by stating that the diagnosis in each case was verified by the 
attending physician, Dr. Wm. H. Draper, and that careful daily 
examinations were made by Dr. J. Haven Emerson, the talented 
house physician of the Hospital. 

Case I. — G-., set. 28. Steamship fireman. 

Admitted Jan. 11th, 1866. Was taken ill on 6th with chill, pain in right 
side, etc. 

On admission, considerable febrile disturbance Of rather low type; tongue 
much coated, iuclined to dry in middle ; general condition fair. Physical ex- 
amination reveals dullness, bronchial breathing and voice, and crepitant rale 
over limits of right upper lobe; most marked in supra-spinous fossa. Ex- 
pectoration characteristic. Is ordered decubitus, an oiled-silk jacket, at 
night a Dover's powder, and 

Py. Pulv. ipecac, .12 

Liq. amnion, acetat., 120. 
M. Cap. one tablespoonful q. 4. h. 

Jan. 12. Consolidation progressing; expectoration thiu, containing some 
pure blood ; had epistaxis yesterday ; tongue rather dryish and brown coated. 
Ordered, Sherry wine, 180 cc, to be taken with milk; continue mixture. 

Jan. 15. Defervescence occurred during last twenty-four hours, with a fall 
of 3.5° C. (See table.) General bronchitis has supervened, and masks the 
physical signs in the affected lobe. Tongue is quite moist and cleaner. Stop 
mixt. 

Jan. 17. Quite convalescent. Ordered, continue wine and take quinine 
sulph., .12 t, i. d. 

Jan. 27. For a week has sat up and been about. Bronchitis is gone, and 
he is discharged cured. 

Case II.— R. S., set. 26. Seaman. 

Admitted Jan. 16th, 1866, having been ill four days. Sickness began with 
chill, pain in right side, fever and cough. 

On admission he presents all the objective signs of pneumonia, involving 
the right lower lobe, in stage of red hepatization; expectoration rust-colored; 
general condition good. Ordered, decubitus, and at night 1 c. c. of Squibb's 
liq. opii co., and the ipecac, mixture, as given above, every four hours. 

An oiled silk jacket, lined with cotton, was applied over the chest. 

Jan. 21. A small fall in the evening temperature indicates the limitation 
of the disease. A pleuritic friction sound is heard at the angle of the scap- 
ula. Cont. treatment. 



THERMOMETER IN CLINICAL MEDICINE. 3 

Jan. 23. Yesterday complete defervescence did not occur, because the in- 
flammation extended to the upper lobe of same side ; tympanitic dullness is 
found over the angle of the scapula. Defervescence did occur this a.m. Yes- 
terday, patient had a little epistaxis and diarrhoea, which latter was checked 
by suppos. opii, (.12) p. r.n. Expectoration less colored, more abundant and 
inuco-purulenL Cont. treatment. 

Jan. 24. Vital signs down to normal standard. 

Jan. 31. Resolution took place rapidly; patient has been up for a few 
days. Some dullness remains at apex and over lower lobe, and at the angle 
of the scapula are still heard pleuritic friction sounds, some subcrepitant rales 
and broncho-vesicular breathing. 

Feb. 5. Patient is discharged, cured. 

Case III. — S., set. 19. Coal-passer on steamship. 

Admitted Jan. 25th, 1866. Illness began on 21st with chill, pain at lower 
ribs of right side, cough and fever. 

On admission there is much pain, great febrile movement and dyspnoea; 
expectoration rust-colored, very characteristic ; patient presents all the physical 
signs of inflammation involving the right upper lobe. General condition excel- 
lent, except previous malarial poisoning. Ordered, an oiled-silk jacket, a 
hypodermic injection of morphia (.60 of Magendie's sol.) and the mixture used 
in the cases above, in the same doses. Decubitus. 

Jan. 27. There is complete hepatization of affected lobe. Defervescence 
occurred during last twelve hours, with a fall of 3.7° C. Had epistaxis yester- 
day. Continue treatment. 

Jan. 29. Subcrepitant rale (rale crepitant redux) is heard over upper lobe ; 
expectoration muco-purulent, hardly at all colored ; no fever. Stop mixture. 

February. Patient convalesced very rapidly, and only remains in the hos- 
pital for the treatment of a malarial element. 

In a few words these three cases may be summed up. 

But first, the word " defervescence " used in these histories 
and in the abstract below needs definition. It is new to Ameri- 
can medical literature, having first been used by the learned 
professors of the German schools, to express in one word the 
cessation or subsidence of the febrile phenomena of disease. It 
has been very recently adopted in England, and finds a prominent 
place, as well as the entire subject of thermometry, in Aitken's 
"Science and Art of Medicine." 

In reading the cases and looking over the table of vital signs, 
the first thing to be remarked is, at what a late period of the 
disease the patients were received ; the most recent on the 
fourth day. This, however, is a difficulty which attends all in- 
vestigations made upon hospital subjects ; but, fortunately, in 
other places the disease has been studied so early as to deter- 



THERMOMETER IN CLINICAL MEDICINE. 



RECORD OF VITAL, SIGNS. 


DAYS OF DISEASE 5 6 7 8 9 10 


6 7 8 9 10 11 12 


4 5 6 7 


S 

< 
OS 

o 

1- 

z 

Hi 

o 

0) 

111 
u 
be 
O 
m 
Q 


42° 


































41° 






























> 


\/ 




40° 


/ 


r 


/ 


\ 
























V 




39° 


-» 














4 




/ 




I 












38° 








1 


A 






y 


f 


7 


\ 




V 










37° 










f 














4J 




\ 






V 




































v. 


UJ 

h 

D 
Z 

i 

DC 
UJ 
Q. 
(0 

h 
< 

Hi 

CQ 
UJ 
(0 

-J 

Q. 


140 




































130 






























2 

i 






120 


8 \ 


































110 




v 


** 


\ 








2^ 
















1 




100 








\ 










,8/A 


\4 












*i 




90 








\ 


2 












v_ 










1 




80 










I. 
















\o 






, 




70 










8 
















^ 






•\ 


kP 


60 




























t 








CO 

Z 

o 

h 

,<£ 
CE 

Du 
CO 

u 

OC 


50 


































4 

1 


45 






























1 


8" 


40 




} 


2 

A 














2 










,7* 


35 


V 


1 


•' v 


Y 










8 / 




\8 












\ 


30 
















2/ 


/» 






\ . 








_2 




25 








9 1 - 


8 


7 














8* 


N-6 






A 


20 









































































THERMOMETER IN CLINICAL MEDICINE. 5 

mine very conclusively that the increase of fever is rapid, and 
that a very high temperature may be expected within the first 
twelve hours. In cases I. and III., which were typical of simple 
acute inflammation of one lobe, the temperature, high at the 
beginning of the observation, continued to rise, or did not fall 
except in so far as the regular morning remissions were con- 
cerned, until a certain point of the disease had been reached, 
the ninth day in one case and the fifth in the other, and not till 
the ascending pathological changes had been wrought ; in other 
words, not until hepatization of the implicated lobe was fully 
established. This fall in heat, pulse and respiratory move- 
ments (defervescence) was complete in case III., the thermometer 
never again rising above 37° C. In case I., the same was true, 
with the exception of a single moderate elevation in the even- 
ing of the tenth day. Case II. was remarkable for the low in- 
tensity of the fever. The defervescence was partially effected 
on the ninth and tenth days, but during the evening of the lat- 
ter an alarming increase of 1.75° C. led us to suspect that the dis- 
ease had invaded a second lobe, when it will be noticed that the 
pulse and respirations (80 and 30 respectively) gave no warning. 
Physical examination showed that the thermometer was right. 
The next morning defervescence occurred fully and finally in the 
course of two days. It may also be seen how accurately the es- 
timation of the heat determines the cessation of ascending path- 
ological changes, and marks the beginning of those processes by 
which the vital actions restore the parts affected, and the system 
generally, to a state of health. That the third period of pneu- 
monia is a resolution, is confirmed by the fact that, in normal 
cases, the temperature never rises above 37.25° C. after hepati- 
zation is complete. Were it true that this disease ends by a 
suppurative stage, the thermometer would doubtless remain 
high until the process was completed. 

In these two points the diagnosis of disease and of complica- 
tions, and reliability as an element of prognosis, lies the great 
value of this means of observation. To go into all the facts 
necessary to sustain these positions would require more space 
than can be allowed to a hospital report intended simply to call 
attention to, and invite trial of, the ma+ter in question. Suffice 
it to say, that Prof. "Wunderlich, of Leipzig, has, with others, 
so thoroughly investigated the subject before giving it to the 
profession, that he. made no less than half a million careful ob- 



6 THERMOMETER IN CLINICAL MEDICINE. 

servations, and ascertained the temperature-variations of nearly- 
all diseases so accurately that his pupils can, by merely looking 
at the diagrammatic record of a case, almost always correctly 
diagnosticate the disease without having seen the patient or 
heard of any other symptoms. He and many other leading phy- 
sicians make constant use of the thermometer in private prac- 
tice. The limited trial made in this hospital has not at all 
lowered the expectations raised by reading the published ac- 
counts ; in many cases a diagnosis has been arrived at, and a 
complication detected long before the other objective signs would 
have enabled us so to do. More especially are the distinctions 
of fevers into the great types of typhus, typhoid, remittent and 
intermittent, clearly indicated and not to be mistaken. A last 
point urged is, that the surface heat, as measured in the axilla, 
is not liable to variations from the nervous, emotional causes 
which render the pulse and respiration so very changeable and 
unreliable. Being the direct result of the molecular changes 
produced by pyrexia (although the precise relation of the degree 
of heat to the amount and proportions of the substances result- 
ing from retrograde metamorphosis is not yet ascertained), it 
cannot be immediately affected by causes acting through the 
senses, which so disturb other objective signs, for instance, the 
sudden arrival of the physician, of a friend, of news, the move- 
ments frequently necessary to the comfort of the patient, or to 
facilitate examination, etc. 

The whole matter of the utility of medical thermometry is 
founded upon the fact, that the normal temperature of the 
human body is invariably fixed within certain limits. Yery 
numerous observations by competent observers have determined 
this. The following are those of Prof. Traube, of Berlin, the 
average of many studies of healthy adults at fixed periods of 
the day, taken in axilla : 

36.8° C, 98.24° F. at 7 a.m. 

37.0° C, 98.69° F. at 10 a.m. After breakfast. 

37.0° C, 98.65° F. at 1 p.m. 

37.1° C, 98.78° F. at 5 p.m. After dinner. 

36.8° C, 98.24° F. at 7 p.m. 

As to daily practice with the thermometer, the instrument 
should be an accurately made one, perfect in every respect. 
Those used abroad (not at present to be had in this country) are 



THERMOMETER IN CLINICAL MEDICINE. 7 

graduated to fifths and tenths of degrees, and should be pre- 
ferred. However, one graduated to degrees only will suffice, if 
greater care be exercised in reading off the mercury, and a 
practiced eye may even estimate one-eighth of a degree Centi- 
grade on such a scale. In all cases the thermometer should 
have an outer glass casing, to protect it from injury and external 
influences. 

The bulb is to be inserted in the axilla, just beneath the fold 
of the pectoralis major muscle, not too deeply, the forearm of 
that side carried across the chest, and the elbow secured by an 
assistant, or by the patient's other hand. It is left in situ, 
carefully isolated from all clothing, and in perfect contact with 
the skin, for eight, or even ten minutes, being looked at three 
or four times, the last two determining whether the column of 
mercury has ceased to rise ; the degree (and fraction) is then 
read off and registered. While waiting, the physician has time 
to count and record the pulse and respirations, and even to pro- 
ceed with many other points of investigation. If time be pre- 
cious, the bulb may previously be heated about to the expected 
heat and then inserted, when three or five minutes will be 
enough for a correct estimate. With the exception of the anus, 
the axilla is found to be the most reliable locality for the pur- 
pose. 

ABSTBACT OF PEOF. L. THOMAS* PAPER. 

Early observations : 

39.2° C. ; 102.5° F. observed 4 hours after first symptoms. 



40.5° C, 1049° F. 


9 


it 


a 


40.2° C, 104.4° F. 


12 


a 


a 


40.6° C, 105.1° F. 


23 


a 


n 


41.0° C, 105.8° F. 


36 


a 


a 


41.4° 0. 106.5° F. . 


24 


a 


u 



Variations of temperature in regular cases : 

Minimum in morning, maximum in afternoon, and again after 
midnight a decrease. 

Types of fever : 

1st. In no case purely continued. 

2d. Some cases with small differences between the morning 



8 



THERMOMETER IN CLINICAL MEDICINE. 



and evening measurements (0.25° C. to 0.28° C.) have very sel- 
dom been observed, and only for a single day. 

3d. In the vast majority of cases the differences amounted 
to 0.5° C. to 1.2° C. 

4th. More than once differences of 1.4° C. have been noted. 

5th. A few cases in which almost complete remissions 
occurred. 

The highest point of fever may be known by an extraordi- 
nary elevation, or by a great fall in the temperature, compared 
with preceding observations. 

The termination of the fever (defervescence) generally occurs 
within forty-eight hours, the temperature sinking to the normal 
standard. The days of defervescence have been carefully noted. 



46 CASES BY THOMAS. 

Days. Cases. 

2d 2 

3d .6 

4th 6 

5th 11 

6th 5 

7th 10 

8th 4 

9th 

10th 2 



107 CASES BY ZIEMSSEK 

Days. Cases. 

2d 0, 

3d 9 

4th 3 

5th 31 

6th 5 

7th . 35 

8th 4 

9th . . 9 

11th . ! . . 8 

13th 3 



Thus out of a total of 153 cases, 45 turned on the seventh day 
and 42 on the fifth. Ziemssen states that in cases in which more 
than one lobe is involved, the defervescence is likely to be put 
off until the eleventh or thirteenth day. Thomas is, however, 
inclinded to doubt this, for in 18 of his cases, in which more than 
one lobe was affected, he observed but two in which the pyrexia 
did not subside by the seventh day ; and those on the tenth. 

Defervescence is affected by the lobes as follows : 

Eight upper lobe — 1 on second day ; 4 on seventh ; 1 on eighth. 
Eight lower lobe — 2 on fourth ; 4 on fifth ; 2 on sixth ; 1 each 

on seventh, eighth and tenth. 
Left lower lobe — 1 on second ; 5 on third ; 2 on fourth ; 6 on 

fifth ; 1 on eighth. 



THERMOMETER IN CLINICAL MEDICINE. 9 

Temperature towards fatal termination : 
Majority of cases ending in delirium : 

2 on sixth day, 41.4° C, 106.5° F. and 40.9° C, 105.6° F. 

1 on seventh, 43.0° C, 109.4° F. 

2 on eighth, 41.3° C, 106.4° F. and 40.5° C, 104.9° F. 
1 on fourteenth, 42.7° C, 108.9° F. 

In one case ending with furious delirium, hallucinations, tris- 
mus and tetanus, an elevation of 3.8° C. occurred in six hours. 
In three cases dying of suffocation (asthenia and apncea), there 
was no elevation towards the agony ; in two there was great em- 
physema, and the temperature remained between 38.5° C. and 
39.75° C. ; in the third, accompanied by a fever of great regular 
remissions, the last estimate was 37.5° C. 

For further details and general information the reader is 
referred to the Archiv der Heilkunde, of Leipzig ; to Aitken's 
Science and Art of Medicine, and to articles in the London 
Medical Times and Gazette, for 1858 and 1861. 



ON THE SUBCUTANEOUS USE OF SULPHATE OF 
QUININE IN CASES OF MALAEIAL NEURALGIA.* 

The following cases are taken from the Medical Case Book of 
the New York Hospital, to illustrate the effect of quinine in- 
jected hypodermically over the seat of pain in neuralgias due to 
blood poisoning by malaria. Previous to December, 1866, all 
such cases had been treated by means of quinine and iron, given 
internally, and blisters put over the affected part. The success 
of this, the ordinary plan of treatment, as may be seen in cases 
I., II. and VI., was hardly satisfactory. From three weeks to 
three months seems to have been the usual time of hospital 
residence. 

The first case related had already been under treatment for 
five weeks, without benefit, when Dr. Win. H. Draper, the at- 
tending physician on duty, directed the injection of quinia in 
the manner described. The success obtained exceeded our most 
sanguine expectations ; in four days the pain was relieved, and 
in four more a complete and permanent cure was effected. Thir- 
teen injections, of 1.15 cc. each, had been employed; some 
swelling, induration and tenderness remained where the medi- 
cine had been introduced, but these soon disappeared. 

The solution employed was the one that for more than two 
months we had been using hypodermically in cases of malarial 
fever, and was made according to the formula on page 15. 

The injections were given in the following manner : A fold of 
skin being taken up and firmly held between the thumb and fore- 
finger of the left hand, the point of the- syringe was introduced 
at the top of the fold, where a partial anaesthesia had been in- 
duced by the pressure ; the needle being put in its full length, 
the solution was forced in gradually as the needle was with- 
drawn, so as to throw the injection as much as possible into the 
track of the wound, and to cause the least rupture of the sur- 
rounding connective tissue. After taking out the needle, a 
little circular friction was generally used, with the view of as- 

* From the New York Medical Journal, August, 1867. 



QUININE SUBCUTANEOUSLT IN NEURALGIA. 11 

sisting the absorption. The slight haemorrhage sometimes fol- 
lowing the operation was easily controlled by finger pressure. 

The immediate effect of such an injection is a pretty severe 
burning pain being felt in the part, due, most probably, to the 
acid and irritating property of the solution. This pain usually 
passes off within twenty minutes. 

Within two hours of the depositing of the injection under the 
skin, some swelling and induration of the part begin to show 
themselves, without heat or redness, and apparently owing to 
the occurrence of a fibrinous exudation. Usually, in the course 
of a day, this induration reaches its maximum, and afterwards 
decreases slowly, and disappears within the fortnight. Some- 
times, in delicate tissues or when the injection has been given 
hastily, some degree of ecchymosis makes its appearance in the 
course of two days. Later, the therapeutic effect of the medi- 
cation shows itself in the arrest of the paiij and hyperesthesia, 
followed in some instances by slight though distinct anaes- 
thesia. No abscess or other unpleasant consequence has fol- 
lowed any of the seventy-eight injections used in these six cases. 

The modus operandi of the hypodermic injections of quinia may 
be said to be threefold. 1st. By absorption of the drug into the 
general circulation, whereby it obtains its specific effect, tending 
to the removal of the cause of the neuralgia. 2d. By the direct 
therapeutical action of the quinia on the nerves and cellular ele- 
ments of the part affected. 3d. By pressure ; a purely mechan- 
ical effect of considerable importance, due to the large quantity 
of fluid used and to the amount of exudation thrown out. 

Case I. — A., aet. 30. A seaman. 

Admitted November 5, 1866. Has had intermittent fever (contracted in 
Aspinwall) more or less for four weeks ; last chill being on the 6th inst. Has 
suffered from pain over spleen ; evidently a neuralgia affecting the lower in- 
tercostal nerves. The spleen itself is a little enlarged, and tender underpress- 
ure. Patient is considerably cachectic. Quinia and chalybeates ordered. 
Locally, dry cups, tine, iodine, and blister applied. Dec. 13. Has had no 
chills, but neuralgia is about as severe as at time of admission. Ordered a 
pill of quiniae sulphat., .12; and bellad. extract., .015; to be taken thrice 
daily. 

Dec. 19. Pain is no less ; sharp and nearly constant in left hypochondriac 
region. Stop pills; continue quiniae sulph., .12 ter in die, and the iron. 
Ordered local injections of 1.15 cc. solution of quiniae, night and morning. 
Dec. 23. No pain to-day. Continued one injection a day. Dec. 28. Stop in- 
jections, as pain has not returned. Continue internal treatment. Jan. 7. 
Patient is discharged cured. 



12 QUININE SUBGUTANEOUSLT IN NEURALGIA. 

Case II. — M., aet. 29. A seaman. 

Admitted Nov. 2, 1866. During the last two months patient had quotidian 
intermittent fever, contracted in Aspinwall. 

From the first had more or less pain over the region of the spleen, running 
towards the epigastrium ; of late the pain has been quite severe. Patient is 
cachectic and weak. Ordered quinia in sufficient doses to arrest chills ; the 
citrate of iron, together with good food, and 250. cc. sherry wine. Nov. 19. 
There is much general improvement, but pain in left side is about the same. 
Spleen is badly enlarged. Ordered a blister locally. Stop quinia, but continue 
iron. Dec. 12. Blister has been repeated, but pain remains the same ; ordered 
an injection of quinia, 1.15 cc, injected over seat of pain twice a day. 
Dec. 15. Neuralgia is gone from the side, but patient is seized with a severe 
hemicrania of left side. Continued injections and the iron ; ordered quinia, 
.12, ter in die. Dec. 20. Injections were now given in shoulder, near 
neck. Dec. 28. Hemicrania well ; no return of pleurodynia, and nc chills. 
Stop injections. March 2, 1867. Patient has remained, on account of sore 
throat and conjunctivitis. Is to-day discharged, cured. 

Case III. — C, oet. 31« A seaman. 

Admitted February 1st, 1867. Patient eight months ago had a severe at- 
tack of intermittent fever. He contracted a diarrhoea at Aspinwall, one 
month ago. Soon after, he began to complain of a severe paroxysmal 
pain in the epigastrium. 

On admission, the diarrhoea has ceased, but the tenderness and pain con- 
tinue in the skin over the upper part of the abdomen. There is also a de- 
cided tenderness developed by pressure on the sixth and seventh dorsal ver- 
tebra?. Feb. 3d. Ordered 2.2 cc. of solution of quinia injected in epigas- 
trium. As patient is decidedly cachectic, he takes bark and iron, with quinia, 
.12, ter in die. Feb. 8th. Yesterday, neuralgia had ceased; the injection 
is reduced to 1.15 cc. Feb. 11th. Has no pain; stop injections, but continue 
internal remedies. March 2d. Is now well. Some induration still remains 
where injections were put in. Discharged, cured. 

Case IV. — Same patient. Re-admitted April 12th. 

He went back to Aspinwall, and, three weeks ago, the pleurodynia returned, 
locating in the epigastrium, and entire right side of chest, up to clavicle. Pa- 
tient is quite cachectic, but spleen is only a trifle large, and the liver normal in 
size. The pain is rather worse at night, but there is no febrile movement. 
Ordered calomel, .60, followed by 30. cc. ol. ricini. April 14th. Ordered 
quinia, .12, ter in die, and mixture of bark and iron. Also a hypodermic 
injection of quinia, .25 (2.2 cc), every morning, over seat of pain. April 16th. 
Pain has ceased ; continued treatment. May 4th. Patient has had no return 
of [pain. Subsequent to the arrest of the neuralgia he had an attack of 
dysentery and one of gout; both easily mastered. Is to-day discharged, 
cured. 

Case V.— S., oet. 32. A seaman. 

Admitted April 10th, 1867. Patient comes from a southern port. Has had 
no attack of malarial fever. For last three months has suffered from severe 



QUININE SUBCUTANEOUSLT IN NEURALGIA. 13 

wain in the right side of back, running up to the shoulder. The iiver is 
slightly enlarged ; there is no pleurisy. General condition good. Ordered 
house mixture of bark and iron", and an injection of 2.2 cc. solution of 
quinia, each morning, about angle of scapula. April 30th. Hypodermics 
stopped. Patient has none of his pain. A stitch is occasionally felt in 
various parts of his chest. May 3d. Is discharged, cured. 

Case VI. — S., set. 46. A seaman. 

Admitted April 23d, 1867. About rive weeks ago, patient had quotidian 
intermittent, which was contracted in a southern port. He had only a few 
paroxysms, when there appeared a sciatica of the left thigh, which has con- 
tinued till now. Patient states that he never has had any rheumatism; but, 
that, one year ago, he had a severe attack of Aspinwall fever. 

[In August, 1865, this same man was received into the house, with a similar 
sciatica, contracted in the same way, which resisted the ordinary anti-rheu- 
matic treatment for three months (by means of colchicum, iodide of potassium 
and blisters), and finally yielded to quinia and iron, given internally.] 

Patient is ordered the mist, ferri et cinchona? of the house, and hypodermic 
injections of quinia, .25, in morning, over course of left sciatic nerve, be- 
ginning above. May 1st. Almost no pain in thigh. Patient complains of 
anaesthesia along course of nerve below injection ; some pain remains below 
knee; continue treatment. May 4th. No more injections since yesterday; 
neuralgia is substantially cured; continue tonics. May 7th. Complains of 
some pain in right sciatic nerve. May 13th. Had two injections of 2.2 cc. 
over right nerve, and pain ceased. To-day sent out cured. 

In looking over these cases, some instructive points are seen. 
No doubt can be reasonably entertained as to their nature, with- 
out calling into question the existence of the class of malarial 
neuralgias. These men were all seamen of the southern trade, 
some going as far as Aspinwall ; they all suffered from remittent 
or intermittent fevers before the onset of the pain ; in every one 
the malarial cachexia was present ; they were all, with one ex- 
ception (Case IY.), free from the rheumatic taint; in all but 
Case YI. the disease affected the branches of the intercostal 
nerves, the lower ones by preference ; and in these cases careful 
examination failed to reveal pleuritic effusion or friction sound. 
In all instances there was a marked hyperesthesia of the integu- 
ments of the seat of the pain ; in none anaesthesia. In only two 
cases (III. and IY.) w r as tenderness found over the spinal process- 
es, corresponding to the origin of the involved nerves (apophysal 
point of Trousseau). In Case II. a complete metastasis occurred 
from the left hypochondriac region to the left side of the head 
and face ; and in Case YI. from the left to the right sciatic 
nerve. In none of these cases was the pain intermittent, nor 



14 Q TJININE S UBG UTANEO USL Y US' NE URALGIA. 

was it ever of the same intensity during the twenty-four hours, 
being usually more distinct in the afternoon. 

As to the merits of the plan of treatment, to say that it is 
specific would be a reckless assertion. To deny it very great 
efficacy would be to reject the testimony of the above cases. 
That the internal administration of quinia and iron must be kept 
up during the treatment by injections, and continued for some 
time after the pain has increased, is evident from a consideration 
of the pathology of the disease ; and that the above-named 
remedies alone will cure this form of neuralgia is not denied ; 
but the history of the first attack of Case YI ., in 1865, and the 
account of the beginning of cases I. and II., show how often blis- 
ters may be applied, and how long tonics may be given without 
alleviation of the symptoms. 



ON TBEATMENT OF MALAEIAL FEVERS BY THE 
SUBCUTANEOUS USE OF THE SULPHATE OF 
QUININE.* 

Quinia seems first to have been subcutaneously employed by 
Dr. Chasseaud, of Smyrna, who in 1862 reported one hundred and 
fifty cases of malarial fever thus successfully treated. He claimed 
greater rapidity of action and economy in the use of a costly 
medicament as the advantages of the new plan. About the same 
time a similar attempt was made in France by Goudas,t who 
published fifteen cases, and Moore X nsed Chasseaud's method in 
India. During the winter of 1864-5, Dr. Maury § treated some 
twenty-five cases of intermittent fever in the rebel hospital at 
Greenville, Alabama. In 1865 Mr. Craith, || of Smyrna, continued 
to give quinia hypodermically with flattering and constant success, 
while Desvigne in France, Eulenberg 1" and Lorent** in Ger- 
many, were making some few successful experiments. 

This method was first tried in the New York Hospital by Dr. 
G. M. Smith, the attending physician then on duty, in a case of 
congestive remittent fever, during September, 1866. It has since 
been applied to all varieties of malarial fever, and may now be 
said to be a part of the regular practice of the house. 

The solution of sulphate of quinia used in the hospital is made 
according to the following formula : 

Take of subsulphate of quinia, 4. ; dilute sulphuric acid, 
2.4 cc; distilled water, 31. cc. Mix. Make a solution and filter 
with the greatest care. 

*From the JV. Y. Medical Journal, December, 1867. The material for this 
and the preceding essay was collected by the author while House Physician of the 
New York Hospital, 1866-7. [R. W. A.] 

f I! Union Medicate, 1862. % Lancet, August 1, 1863. 

§ American Journal of Medical Sciences, Oct., 1866, p. 371. 

|| Letter to Med. Chir. Society of London, December, 1865. 

1[ Die Hypodermatische Injection der Arzneimittel, etc. Berlin, 1865. 

**Die Hypodermatisehen Injectionen nach clinischen Erfahrungen. Leipzig, 
1865. 



16 TREATMENT OF MALARIAL FEVERS. 

2.2 cc. of this are equal to .25 of quinia. 

Or the solution may be varied by the addition of .25 or .36 
of sulphate of morphia, which combination renders the injection 
less painful. 

The mode of giving an injection of this solution by means 
of an ordinary hypodermic syringe, has been fully detailed on 
page 10.* 

At first less acid was used, for fear of causing irritation, but it 
was soon discovered that the real causes of abscess were the un- 
dissolved crystals of quinia and the particles of dust which im- 
perfect closing of the bottle allowed to drop into the fluid. It 
was also found that an excess of acid removed the most fertile 
source of danger, while it but slightly increased the pain of ad- 
ministration. In reality, there is but little more acid in the 
above formula than in Moore's, for he used twelve drops of the 
'pure acid to dissolve 2. of quinia in 16. cc. of water. Dr. Maury, 
of Alabama, employed a solution, 4. cc. of which contained .50 of 
the salt. 

From the fact of sailors being received into this institution 
as' patients, malarial fevers form a large part of the practice of 
the house. These cases come in mostly from the various ports 
of our own Atlantic and Gulf coasts, and from Cuba, the West 
Indies, Mexico, and Central America. In many of these ports 
(Aspinwall, Mobile, and "Wilmington being the worst) the poison 
is most intense, and produces not only severe attacks of fever 
proper, but also deep and long-continued cachexia. Congestive 
cases come in during the summer and autumn from the three 
above-named places, and are of a very fatal character. These pe- 
culiarities of the fever necessitate the exhibition of much larger 
doses of the anti-periodic medicine than are usual in Northern 
practice. Besides the amount of quinia required for the break- 
ing of the attack, the prolonged use of small doses combined 
with iron is resorted to, in order to correct the cachexia. 

The usual treatment of these cases has been as follows for 
the past few years : 

A simple intermittent of the tertian type was cut short by the 
giving of three doses of .30 of quinia two hours apart, and 
so calculated that the same interval of time should intervene 
between the last dose and the expected chill. 

* New York Medical Journal, August, 1857, p. 403. 



TREATMENT OF MALARIAL FEVERS. 17 

A quotidian usually required four such doses given in a sim- 
ilar manner. In both forms, subsequently to the stoppage of 
chills, some .36 of quinia were given daily, together with some 
form of iron ; * on the seventh, fourteenth, and twenty-first 
days (counting from date of last paroxysm) .30 extra were ex- 
hibited about two or three hours previous to the chill time. 

Simple remittent fever was treated by means of .12 doses 
of quinia given every two hours until the headache became 
very severe or the fever ceased. In many cases the medicine 
could be continued for twenty-four or forty-eight hours, when 
the force of the fever being broken, the doses were gradually 
reduced until, in convalescence, .12 three times a day, combined 
with a chalybeate, were ordered, and continued up to complete 
recovery. Severe cases, simple, or tending to the congestive 
form, were treated by hourly doses of .12 or .30 pushed until 
cinchonism became apparent. Of course, it is understood that 
this account only relates to the quinia, its mode of adminis- 
tration, and quantity employed, making no mention of the 
numerous other means resorted to, such as purgatives, local 
applications, stimulants, and food. 

When it was decided to use the hypodermic method it became 
necessary to work out rules for giving the remedy, both as to 
time and quantity, no explicit directions being found in any of 
the published accounts at hand. One single statement there was 
to serve as guide, that .06 of quinia under the skin was equiv- 
alent to .30 or .36 by the mouth, (Moore). In the course of a 
few experiments it was discovered that this was far too high 
an estimate, at any rate for the class of cases coming from the 
South. It was observed that .25 of the medicine were needed 
to break an attack of tertian fever, and that fully .50 were re- 
quired for a quotidian. In congestive cases, of course, the 
amount injected varied according to the severity of the attack, 
and it was always given upon the estimate that .06 subcutane- 
ously equaled .25 by the mouth. By following the experience 
gained while giving mouth-doses, the injections were at the first 
given two hours before the time of the expected paroxysm, and 
this was found so successful that the rule is now invariably fol- 



* The "black mixture," so much used in the hospital as a tonic, is made ac- 
cording to the following formula: Ferri ammon. citrat., 1. ; tinct. cinchon. co., 
31. ec. ; aquae, 95. ec. M. 15. cc. at a dose. 
2 



18 TREATMENT OF MALARIAL FEVERS. 

lowed. Where two injections were required, if there was time 
to spare, .25 were given four and the other dose two hours be- 
fore the expected chill. If the time was too short, both injec- 
tions were given at once. 

The following histories will illustrate the working of the 
method in intermittent fever : 

Case I. — B , a seaman, set. 28, admitted June 22, 1867. Comes from 

Florida and has had quotidian chills for eight days; paroxysms at noon, re- 
tarding a little. On admission is rather feeble. |June 23. — To-day had a 
hypodermic injection at 10 a.m. (.25), but at 1 p.m. had a severe chill. 
24th. — No chill to-day. This morning had .25 at 10 a.m., and the same 
at 11 a.m. Ordered mist, ferri et cinchon. of house, 15. cc. thrice daily. 
July 1. — Yesterday had .25 under the skin at 11 a.m. No chill. Continue 
mist, ferri. 3d. — Is sent out well. 

• 

Case II. — V , a seaman, set. 19, received July 17. Comes from Savan- 
nah and has had an attack of tertian ague twelve days. Last chill occurred 
at 4 o'clock p.m., yesterday. General condition is fair; bowels are open. 
July 19. — Yesterday had .25 of quinia under skin at 1 p.m. (as chills antici- 
pate a little), and had no paroxysm. Ordered mist, ferri et cinchon., 15. cc. 
thrice daily, and as there is some cachexia, quin. sulph. .12 thrice daily. 
24th. — Yesterday being weekly anniversary of chill, had .25 subcutaneously 
at 1 p.m. Is much improved in appearance and has had no chills. Discharged 
cured. 

Case III.— W , a seaman, set. &2, admitted April 23, 1867. Patient has 

had a quartan intermittent fever contracted in East Indies, fifteen months, off 
and on. Has never been free from chills for more than six weeks at one time. 
He states that from the first every chill has been accompanied by a crop of net- 
tle-rash. On admission, general condition is pretty good, though the spleen is 
a little enlarged. On 21st had a severe chill at 3 p.m. April 25. — Yesterday, 
at 3.30 p.m., had a severe chill. About twenty minutes before attack he 
called attention to an eruption, clearly of urticaria, covering the entire body, 
and causing intense itching and burning. His pulse was then accelerated and 
the axilla heat was about 39.5° C. To-day takes quin. sulphatis, .12, thrice 
daily, and the tonic iron and cinchon. mixture. 28th. — Yesterday had quinia, 
.25, hypodermically at 11 a.m. and 1 p.m., but chill occurred about 5 o'clock, 
accompanied, as usual, by nettle-rash. Continue small mouth-doses and 
mist, in interval. May 1. — Had injections of .25 at 10 a.m., 12 m., and 
2 p.m. yesterday, and escaped chill. Continue tonic treatment. May 26. — 
Patient has had no return of chills. Had quinia, .25, on anniversary days 
(May 4, 11, 18 and 25,) and has kept up black mixture. "Region of spleen has 
been occasionally painted with tr. iodine. Since 14th inst. has also taken 
a little of Fowler's solution. 27th. — Is discharged at request, nearly well. 

These three cases give a correct idea of the general manage- 



TREATMENT OF MALARIAL FEVERS. 19 

ment of the common intermittents. In many instances no quinia 
was given after the last chill, excepting the .25 on anniversary 
clays, thus making an immense saving in the nse of the medicine, 
not more being employed in the entire course of many cases 
than was formerly needed to avoid a single paroxysm. Up to 
August 6, thirty-five such cases have been treated with perfect 
success. 

In the remittent form, the experience is small and not satisfac- 
tory. In two cases, from one to four injections were given in 
the remissions, but with little effect on the fever, while the num- 
ber of injections caused considerable annoyance to the patients. 
Although the experiment has not been repeated in the hospital, 
yet further trials should certainly be made, when a time and 
mode of giving the medicine may be found which shall lead to 
success. 

In about ten congestive cases the results have been satisfac- 
tory, though, as usual, the mortality has been very great. In only 
one or two cases have the injections been used alone, being 
usually employed as an accessory to the ordinary treatment of 
quinia and whiskey given by the mouth. The following case 
reported at the time by Dr. H. D. Bulkley* (the treatment of 
which was personally attended to by the writer), is an interest- 
ing one, and is worth reproducing here as illustrative of the new 
method : 

" , a stout, well-developed sailor, forty-four years of age, was brought 

into the hospital at 8 a.m., October 8, in a state of collapse from a chill the 
night before, from which lie had not rallied. His skin was cold and clammy; 
pulse could not be felt at the wrist ; considerable dyspnoea and anxiety, with 
some laryngeal hoarseness ; tongue slightly coated, white, pale, and quite 
cold. He was conscious and rational.' but could only speak in a whisper, and 
there was great thirst. As the stomach was not irritable, 15. cc. of whiskey 
was given every half hour, and ice to allay the thirst. The treatment 
was commenced by a stimulating enema, dry cups to chest, and sinapisms to 
the nape of the neck and legs ; and to avoid irritating the stomach, and for 
speedier effect, quinine in solution was injected under the integument of the 
upper part of the chest — .25 at 8.20, 9.20, and 11 a.m., and 1, 2, and 3 p.m. ; 
and about the middle of the day three doses of .30 each were given by the 
mouth at intervals of half an hour; but as this disturbed the stomach it was 
discontinued. In the afternoon dry cups were again applied, the use of 
stimulants being continued. At 4.30 and 6 p.m. the hypodermic injections 

* New York Medical Record. Vol. 1, p. 489. 



20 TREATMENT OF MALARIAL FEVERS. 

were again given. At 8 p.m. quinine was given by the mouth, .30 every hour. 
The amount of quinine given hypodermically from 8.20 a.m. to 6 p.m. was 
therefore in all 2.15, estimated to be equivalent in therapeutic value to a little 
over 8. by the mouth. 

" At 3 the next morning (October 9), at the end of nineteen hours, his 
pulse was perceptible, and he became comfortably warm. His voice was now 
stronger, but it, as well as the breathing, indicated larnygeal trouble. 
Nothing abnormal, however, could be seen in the throat, nor could anything 
be felt by the finger. The quinine was continued every hour, and the whis- 
key reduced to 15. cc. every hour, and beef-tea ordered freely during the day. 
At 8 p.m. lie had fully rallied, though there was considerable dyspnoea and 
restlessness, and quinine was reduced to .30 every two hours. In thirty-six 
hours the patient had taken 2.15 hypodermically and 12. by mouth of 
quinine, estimated to be equal in therapeutic value to 15.5 of the salt, jfre 
progressed favorably until the 14th (five days), reaction having been fully 
established ; and both the quinine and whiskey having been reduced in 
quantity. Ecchymosis had taken place at one or two points where the in- 
jections had been made. On that day, however, he became worse. Obscure 
symptoms occurred, made up of laryngeal obstruction and pulmonary and 
cerebral congestion. Stimulants and quinine were now stopped, and 60. to 
90. cc. of blood taken from the nape of the neck. At midnight he became 
quite restless, and persisted in rising to have a stool near the bed, refusing 
to use the bed-pan, when he almost instantly sank back and died, apparently 
from syncope. No autopsy could be obtained." 

This patient was undoubtedly saved from death during the 
algid period by the quinia, and he only died from the effects of 
the secondary disorganization of the blood so common after 
severe attacks of the fever. It is noteworthy that he never had 
a symptom of cinchonism. 

In conclusion, a word as to certain consequences likely to 
result locally from the injections. Abscesses and phlegmonoid 
swellings have been observed in the hospital. In all, out of a 
very large number of injections (one patient receiving over one 
hundred), only six abscesses occurred, and not one of these after 
the middle of last January. In each instance the result was 
attributable to the introduction of insoluble particles along with 
the fluid. Maury reports two abscesses out of twenty-five cases, 
and Moore the same number out of thirty. When trouble 
was about to ensue, the swelling normally consequent upon the 
injection increased after the second day, and redness, together 
with a beating pain, were noted. The centre of the swelling 
was usually soft from the first, and at that place the pointing 
of the pus occurred. These phlegmons were first poulticed 



TREATMENT OF MALARIAL FEVERS. 21 

• 
and then opened early by a free incision. No difficulty was 
observed in their healing. 

Since January there have occurred a small number (not more 
than six) of what have been called phlegmonoid swellings. In 
these, the swellings, redness and heat were present, but the 
beating pain was not, the patients complaining only of a sensa- 
tion of burning. As early as the soft centre became distinct, an 
exploring-needle was introduced, letting out a small quantity of 
serum ; after which the swelling was again poulticed. In all 
these cases complete resolution occurred. 

In numerous instances the patients complained of temporary 
anaesthesia in or about the part where the injections were given ; 
but the place of election in fever cases being the chest, abdo- 
men, and back, no great inconvenience ensued. Ulceration, 
sloughing, and reflex nervous disturbance were never observed, 
nor was cinchonism ever clearly produced. 



THE HYPODERMIC INJECTION OF QUININE.* 

To the Editor of the Medical Record. 

Sir : In your issue of August 1st, 1870, there appeared a letter 
from Dr. Stephen Rogers, in which that gentleman dwells upon 
the danger attending the hypodermic use of the sulphate of 
quinia. . The doctor speaks of the physicians of the New York 
Hospital as having expressed opinions upon the subject. I must 
confess that I have failed to find in the medical journals any 
communication touching this matter, by any of the six gentle- 
men of the medical staff of that institution. However, on read- 
ing Dr. Rogers's paper in the " Transactions of the American 
Medical Association, for 1869," I find that he refers to reports 
published by me in the Neio York Medical Journal.^ It may be 
proper to state that these reports were in no wise inspired by any 
of the attending physicians of the New York Hospital, and that 
no one but myself is responsible for any opinion or statement 
therein put forth. There are many points in Dr. Rogers's paper 
which might call for criticism ; but my object is simply to state 
certain facts and opinions expressed by men experienced in the 
almost daily use of hypodermic injections of quinia, bearing upon 
the main point at issue, viz.: the supposed danger of acid solu- 
tions used hypodermically. This is, it strikes me, a matter of 
importance in the whole field of hypodermic medication, and it 
is important to know if there be any evidence proving that a 
moderately acid solution, thrown under the skin, causes abscess, 
tetanus, cr other grave disturbances. I may here state that not 
one word in the doctor's letter, or in his paper in the " Transac- 
tions of the American Medical Association," 1869, indicates that 
he has ever given a single hypodermic injection of quinia ! How 
far this circumstance qualifies Dr. Rogers to sit in judgment 
upon the question at issue, I leave to the readers of the Record. 

A case of tetanus occurring after a hypodermic injection of 

* From the New York Medical Record of Oct. 15th, 1870. 

f On the Subcutaneous Use of Sulphate of Quinia in Cases of Malarial Neu- 
ralgia.— New York Medical Journal, August, 1867. 

On the Treatment of Malarial Fevers by the Subcutaneous use of the Sulphate 
of Quinia. — New York Medical Journal, Dec, 1867. 



HYPODERMIC INJECTION OF QUININE. 23 

quinia, related by Dr. Sale in tlie New Orleans Medical Journal, 
is referred to by Dr. Rogers, and the post hoc ergo propter hoc in- 
dorsed. We are not afforded proof that no nerve was wounded 
in administering the injection ; that no solid particles (crystals 
of quinia or foreign bodies) entered the subcutaneous connective 
tissue ; nor that the climatic conditions were unfavorable to the 
development of the neurosis— all points, in my opinion, worthy 
of investigation before deciding that the tetanus was " produced 
by the administration of quinia hypodermically." 

The report of the committee of the Royal Medical and Chi- 
rurgical Society * is most unsatisfactory, and fails to meet the 
requirements of modern experimental physiology. The com- 
mittee do advise against the use of acid or strongly alkaline 
solutions ; while nothing in their report appears to show that a 
well-made acid solution produces inflammation. The abscess 
which they had to treat, after an injection of quinia, was pro- 
voked by the introduction of 30 cc. (!) of solution into the 
areolar tissue. Nowhere do they refer to the necessity of care- 
fully filtering solutions, or to peculiar care in the cleansing of 
the syringe. Those who first employed the method — Chasseaud, 
Moore, Desvigne — were unfortunately obliged to use very imper- 
fect syringes, or even to introduce the solution of quinia through 
an incision ; consequently, the local troubles which they had 
to deal with cannot rightfully be brought into this inquiry. 

Now for the opinion of more recent writers on the subject. 
Chas. Hunter (Lancet, 1863, vol. ii., p. 444), speaking of hypoder- 
mic injections of quinia, says : "But is there no fear of abscess 
or diffuse inflammation following the puncture ? So frequently 
have I asked the question, that I may take the present oppor- 
tunity to reply : No, certainly not." He then speaks of various 
precautions to be observed in attempting this method, and adds, 
without giving any facts to support his position : " To employ a fluid 
otherwise than neutral would also irritate. True, some fluids 
cannot be made perfectly neutral, but so nearly so that no irri- 
tation occurs." The difference between a nearly neutral and a 
slightly acid fluid is rather difficult to ascertain, I imagine. An 
even greater authority, probably the best writer and experimenter 
on hypodermic medication, A. Eulenberg, is even more explicit 
in his statement. t On page 40 he states that he has never seen 

* Medico- CMrurg. Trans., 1867. 

f Die Hypodermatische Injection der Arzneimittel, n. s. w., Berlin, 1867. 



24 HYPODERMIC INJECTION OF QUININE. 

local inflammatory trouble follow hypodermic injection of quinia 
in his own practice ; adding, that in the practice of a colleague, 
a swelling, at first painful, lasting one month, ensued after the 
injection of a " turbid " solution. And yet Dr. Eulenberg's for- 
mula is so like that of the New York Hospital that it must be 
startling to one who sees in dilute sulphuric acid a fertile cause 
of abscess, tetanus, etc. Eulenberg directs quinise sulph. 4.; 
acid sulph. dil. q. s.; aquse distil. 31. cc; to be mixed and filtered. 
How far the q. s. in this solution differs from the 2.5 cc. in that 
used at the New York Hospital, I leave to pharmaceutists to 
determine. 

In the New York Hospital, quinia was first used hypoder- 
mically in Sept., 1866, and this " abuse " of quinia was continued 
until the breaking up of the institution in Feb., 1870. At first, 
all cases treated in this way were recorded with care ; but dur- 
ing the last two years of this period hypodermic injections were 
looked upon so much as a matter of routine, that, although very 
frequently employed, there are but few cases entered in the case- 
books of the hospital. 

I take the present opportunity of saying, that to Dr. "W. Thur- 
man, resident physician in 1868, is due the credit of making the 
formula, and t>f laying down many of the important rules for the 
administration of the solution. The following is the result of 
my search through the case-books of the four years, giving the 
minimum number of cases recorded in those books, and the num- 
ber of abscesses occurring. The latter has been the subject 
matter of oral and written questions addressed to all the resi- 
dents on duty during the four years, so that the abscess list is, I 
believe, absolutely correct. 

W. Thurman, Ees. Phys. April 1 to Dec. 1, 1866; 70 injec- 
tions, 2 abscesses (both in one case). 

E. C. Seguin, Ees. Phys. Dec. 2, 1866, to Aug. 7, 1867; 
318 injections, 4 abscesses (all in one case, and previous to Jan. 
15th) ; one patient received at least 106 injections, taking quinia 
as a tonic, in this manner, without having a single abscess or 
local trouble of any sort. This case alone should decide the ques- 
tion of the danger of acid solutions, as the subject was extremely 
anaemic and feeble, and was therefore well disposed to inflam- 
matory manifestations. It was during the period of eleven months 
that the six "phlegmonoid swellings" occurred, and were suc- 
cessfully treated. 



HYPODERMIC INJECTION OF QUININE. 25 

T. Skelding, Ees. PKys. Aug. 8th, 1867, to April 8th, 1868 ; 115 
injections, 1 abscess (fluid thrown into cutis proper). 

J. Yanderpool, Kes. Phys. April 9, 1868, to Dec. 1, 1868 ; 62 
injections, 2 abscesses. 

[Dr. Y. writes nie that a very large number of injections were 
given in this period.] 

A. H. Buck, Ees. Phys. Dec. 2, 1868, to April 1, 1869 ; 4 injec- 
tions, no abscess. 

[Dr. B. tells me that during his service hypodermic injections 
of quinia were very frequently given.] 

L. D. Bulkley, Kes. Phys. April 2 to Aug. 2,1869 ; 2 injections 
recorded (many given), no abscess. 

G. A. Hathway, Kes. Phys. Aug. 3, 1869, to Feb., 1870; 22 
injections, no abscess. 

The total number of injections recorded on the books is 593 ; 
the number of abscesses recorded and recalled is 9. 

I think, moreover, that the above-named gentlemen would 
concur with me in estimating that at least one thousand injec- 
tions of quinia were given at the hospital from September, 1866, 
to February, 1870. It is noteworthy that six of the nine ab- 
scesses occurred within the first four months of the practice, and 
in two cases. The above residents, without exception, express 
it as their deliberate opinion, that the sulphuric acid in the solu- 
tion is not, per se, a cause of local inflammatory trouble. With 
this view I concur ; and go further, with my friend Dr. Thur- 
man, in thinking that the acid is, by insuring perfect solution of 
the crystals, a source of safety. The ex-residents assign to 
various causes the production of the abscesses falling under 
their observation, such as undissolved crystals of quinia, foreign 
particles in the solution (dust, fungi, sealing-wax), haste in the 
operation, the throwing of the fluid in the cutis, and want of 
care in cleaning the syringe. 

After offering this evidence to the readers of the Becord, I 
feel that something should be added concerning the method of 
giving the solution employed at the New York Hospital. The 
formula for the solution was : " Take of sulphate of quinia, 4.; 
dilute sulphuric acid, 2.5 cc. ; distilled water, 31. cc. Mix ; make 
a solution and filter with the greatest care." 2.3 cc. of this 
solution contain .25 of quinia. 

(a.) The solution was often inspected, and re-filtered when re- 
quired. The hypodermic syringe was cleaned with water always 
(at least during my own term of oflice) before or after use. 



26 HYPODERMIC INJECTION OF QUININE. 

(b.) Of course, in a hospital receiving a large number of cases 
of malarial disease, as did the New York Hospital, the syringe is 
used so much that there is little danger of rust or dust settling 
on any of its parts. In private practice too much care cannot 
be taken in cleaning the instrument often. 

(c.) The following rules for the operation, given in my first 
report, I believe still to be good : "A fold of skin being taken 
up between the thumb and forefinger of the left hand, the point 
of the syringe was introduced at the top of the fold, when a 
partial anesthesia had been produced by the pressure ; the needle 
being put in its full length, the solution was forced in gradually, 
as the needle was withdrawn, so as to throw the liquid as much 
as possible in the track of the wound, and to cause the least pos- 
sible rupture of the connective tissue. After taking out the 
needle, a little circular friction was generally used, with the 
,view of assisting absorption. The slight haemorrhage sometimes 
following the operation was easily controlled by finger-pressure." 

Judging from experience, I unhesitatingly recommend this 
method of giving quinia in the following circumstances : 1st. 
In general hospitals, civil and military, when economy in the 
use of quinia is a desideratum. At the New York Hospital no 
saving was effected on the whole, in the opinion of Mr. Johnson, 
the very capable apothecary of the hospital. This was owing 
to a number of causes, which I cannot enter upon here, but 
which do not prevent me from saying that the method may be 
made economical. 2d. In private practice, in cases of congestive 
fever, when quinia cannot be administered by the mouth, or 
when rapid action is wanted. I do not advocate this to the ex- 
clusion of the injection of the remedy into the rectum, as recom- 
mended by Dr. Rogers, but would remark that well-directed ex- 
periments are needed on this point. 3d. In private and hospital 
practice, for the treatment of neuralgia of malarial origin, in which 
affection remarkable results are obtained by local injections of 
quinia; the drug acting in its specific manner on the system, and 
locally by counter-irritation. Lastly, I may state that Dr. L. D. 
Bulkley has informed me that, while resident in the hospital, 
he several times observed a rapid improvement in the pulse of 
patients affected with a partial collapse subsequent to severe 
haemoptysis, after the simultaneous injection of two, three, and 
even four full doses of quinia (2. 2 cc.) under the skin. 



A STATEMENT OF THE APHASIA QUESTION, TO- 
GETHER WITH A REPORT OF FIFTY CASES.* 

In 1861 the Societe Anatomique of Paris was startled by the 
announcement of Prof. Paul Broca, that the faculty of articulate 
language was to be located in the third frontal convolution of 
the left hemisphere of the brain. In proof of this proposition 
he presented two remarkable specimens, obtained at the death of 
old aphasics, and in the course of the same year other corrobo- 
rative autopsies were made. But, earlier in the year, the subject 
of aphasia (with localization in the left anterior lobe) had been 
the occasion of an interesting debate in the Societe cVAntliro- 
pologie, and at that time very strong negative cases had been cited. 
In the memorable discussion which took place in the Imperial 
Academy of Medicine, in 1865, these negative cases were largely 
increased in number and force. Besides, during the past six 
years, numerous instances of disease have been published in the 
periodicals, favoring and opposing Broca' s view ; so that, to-day 
the question is involved in nearly as much obscurity as ever, and 
an urgent necessity exists that the profession should turn its at- 
tention to the study of cases and pathological specimens, with the 
view of attempting the settlement of the many vexed points. If 
the problem can be solved, medicine will not be the only gainer, 
but a fresh impulse and a new direction will be given to the study 
of the mind. 

The cases which are appended were taken from the case-books 
of the New York Hospital. Four of them (I., II., III. and IV.) 
were observed by the writer during his service as assistant and 
resident physician in that institution. The remaining forty-six 
cases were recorded before aphasia was recognized, and they are 
therefore very imperfectly noted, and are open to challenge. 
But it is to be understood that they are offered only as bearing 
upon the grosser points of the question. It may be here stated 
that six probable cases were rejected because of the insufficiency 
of the record, and two in which speech was much disturbed, on 

* From the Journal of Psychological Medicine, N". Y., Jan'y, 1868. 



28 THE APHASIA QUESTION. 

account of a contradiction as to the side on which the palsy 
existed. 

Aphasia, alalia, aphemia, are three terms of Greek derivation 
which in the last forty years have been employed to designate 
that mental condition, characterized by abolition or abridgment 
of the function of language, without difficulty in articulation and 
without a general affection of the intellect. 

The word aphasia, although revived by Trousseau, is a very 
ancient term for mutism. It occurs [Falret] twice in Homer, and 
is used by a later Greek writer, Sextus Empiricus, who defines 
it almost exactly in our modern pathological sense. Alalia was 
employed by the older physicians to designate loss of speech and 
voice without distinction, until the last century, when Sauvages, 
Cullen, Swediaur, and the two Franks, separated alalia from 
aphonia. Bouillaud, in his first communication (1825) adopted 
the word, but it has since fallen into disuse. Aphemia, a word 
created by Broca in 1861, was soon rejected on account of its 
ambiguous derivation ; as it might, for instance, signify a bad 
reputation. 

The history of the growth of the aphasia question may be 
briefly stated. 

The impulse was given by the great anatomist Gall,* by the 
announcement in 1809, that there did exist a faculty of lan- 
guage, and that it had its seat, its physical organ, in the anterior 
lobes of the brain. He attempted to fortify this position by 
physiological arguments and pathological illustrations. In 1825 
Prof. Bouillaud t supported this hypothesis by the citation of 
numerous cases of injury and disease affecting this part of the 
encephalon, resulting in loss of language. He went further in 
psychological analysis than Gall, recognizing the elements of 
memory of words and that of co-ordinated movements necessary 
to the formation of articulate sounds. In 1836 Dr. Marc Dax, 
(of Sommieres, Dept. of Gard, France), addressed to the medi- 
cal congress of Montpellier a most remarkable work % embody- 
ing his own observations from the beginning of the century, to- 
gether with many from diverse authors, in which he went far 
ahead of his predecessors, and claimed that the faculty of speech 

* Recherches sur le systeme nerveux. Paris, 1809 ; and Anatomie et Physiologie 
du systeme nerveux, etc. Paris, 1810-19. f Traite do l'enceplialite, Paris. 

X Lesions de la moitie gauche de l'encephale coincidant avec l'oubli des signes de 
la pensee. 



THE APHASIA QUESTION. 29 

was localized in the left anterior lobe. It is most extraordinary 
that this memoir, which entitled its author to the priority in the 
investigation of the subject, remained absolutely unknown until 
nearly thirty years later. In 1836 and 1848 Bouillaud again ad- 
vocated his theory, in communications to the Academie de Mede- 
cinc. A report upon a memoir of Dr. G. Dax (a son of the other 
Dax), in the Societe a" Anthropologic of Paris, in the spring of 1861, 
brought about a most animated debate between Bouillaud and 
Auburtin in defence of localization ; Lelut, Gratiolet, and others 
against the hypothesis. One of the results of this discussion, 
was what M. Bouillaud afterward called the "brilliant conver- 
sion " of Broca, who brought forward his specimens, * and car- 
ried localization to its extreme limit ; asserting that the organ of 
speech lay in the posterior part of the third frontal convolution 
of the left anterior lobe. The clinical lectures of Trousseau at 
the Hotel Dieu in 1864 were very valuable contributions to the 
subject ; he being the first to give prominence to the amnesia 
theory of aphasia. During 1865 the French Academy of Med- 
icine was the scene of an almost violent discussion on the sub- 
ject, extending over many meetings, at which the anatomical and 
psychological aspects of the question were debated with great 
learning and eloquence. The volume of London Hospital Re- 
ports for 1865 contained a report of thirty-six cases, by Dr. J. 
Hughlings Jackson, in which he declined deciding for or against 
localization. About the same time quite a number of articles 
on aphasia appeared, in European medical periodicals ; the two 
principal being by Moxon in the British and Foreign Medico- 
Chir. Beview, f and Auburtin in the Gazette Hebdom. for May, 
June and July, 1863. X In the British Journal of Mental Science, 
January, 1867, § Dr. Alexander Kobertson claimed that the es- 
sential lesion was a motor and not a mental one. In this country 
a few cases have been reported by Dr. Austin Flint, Si\, in the 
first number of the New York Medical Record, || and by Dr. Rich- 
ardson in the Buffalo Medical Journal (quoted in Richmond 
Medical Journal, May, 1867). " On December 21st and 27th, Dr. 
C. E. Brown-Sequard, in the course of lectures delivered before 
the New York Academy of Medicine, expressed the opinion that 

* Sur le Siege de la Faculte de Langage Articule, Bull, dc la Soc. Anat. Paris, 
1861. f 1866, Vol. 38, p. 41. 

t Tome x., pp. 318-348, 397-455. § Yol. xii., p. 503. 

|| Yol. i., p. 4. 



30 THE APHASIA QUESTION. 

aphasia was a reflex phenomenon. During the month of May, 
1867, Dr. H. B. Wilbur, Superintendent of the New York State 
Asylum for Idiots, read before the Association of Medical Super- 
intendents of American Institutions for the Insane, an interest- 
ing paper on aphasia, in which he considered some of the aphasi- 
form symptoms presented by the pupils under his care. 

Aphasia may vary in degree from the forgetting of a few 
words to the sad extreme of total deprivation of the power of 
expressing ideas. The former state, consisting, according to 
Trousseau, solely in the amnesia of words, is well exemplified 
by Case II., in which at the time of admission not more than a 
dozen lacunae could be discovered in the vocabulary. Pliny 
notes the case of the orator Messala Corvinus, who only forgot 
his own name. In complete aphasia there coexist amnesia of 
words, amnesia of written speech, amnesia of gestures. In some 
intermediate cases the patient can write ; in others gesticulate ; 
in anomalous instances the power of ciphering or writing music 
(Lasegue) has been preserved when ordinary writing was impos- 
sible. 

In some cases of incomplete and in nearly all complete cases 
of aphasia, involuntary sentences are ejaculated. A reverend 
gentleman, affected with an amnesia of words, was forced to add, 
after the sentence, " Our Father who art in heaven," the words, 
" let him stay there." Another case in point was that of a lady 
seen by Trousseau, who being totally aphasic without paralysis, 
would rise on the coming of a visitor, receive him with a pleased 
and amiable expression of countenance, show him a chair, at the 
same time addressing to him the words " cochon, animal, fichue 
bete;" French words hardly allowed by drawing-room usage. 
Occasionally the ejaculations are meaningless sounds, " cousisi," 
" menomomenlif," " tau" (the only sound made by Broca's cele- 
brated patient). "Women are apt to make use of plaintive or 
semi-religious expressions, "O dear," "good Lord," etc. Men 
of the lower classes may retain oaths remarkably. In all such 
cases, when the attempt is made to teach new words by constant 
repetition, the almost invariable response is the word or sound 
retained by the patient, and which may be termed the aphasic 
echo ; the spoken echo. 

In cases of medium severity some peculiarities are to be 
observed in the writing. One or more words are put to paper 
by the patient, and this written echo often differs from the 



TEE APHASIA QUESTION. 31 

spoken one. The man who said " cousisi " always wrote 
" paquet." When right hemiplegia exists, writing should be 
taught to the left hand in order to investigate the case fully. 

To the statement that gesture is totally abolished at times, 
exception must perhaps be made for the very expressive move- 
ments of the eye, which have not been deficient in any case 
hitherto reported. In case III., while not a sign could be made 
by the limbs not paralyzed, the patient's intelligence, sorrow, 
and impatience were well shown in the glance. 

The state of the intelligence in aphasia has been variously 
estimated by different observers. When there is merely am- 
nesia of a few words, the mind seems to be intact in every 
other particular. In many cases of a complete loss of language, 
business matters may be attended to, amusements may be en- 
joyed, games requiring memory of ideas and of facts together 
with judgment may be played. Later, however, in cases where 
the brain lesion has been severe, progressive imbecility may 
develop itself ; probably due to softening of the cerebral sub- 
stance. Dr. Eobertson seems to consider as a sign of impair- 
ment of the mind, the fact that patients after repeated failures 
to answer questions correctly manifest grief and weep. It 
might be suggested that persons with full command of language, 
and whose mental integrity even Dr. Eobertson would hardly 
dare question, often show equal sorrow at the loss of functions 
or parts of the body of much less importance than speech. It 
would perhaps not be exaggerating to say that the opposite 
state, insensibility to so great a calamity, should be deemed 
a sign of mental degeneration. Eeading, as a test of the integ- 
rity of the intellect, may be reasonably objected to, for the 
reason that there being complete forgetfulness of words, the 
written or printed page is thereby rendered useless. It is as if 
reading a page of Hebrew were deemed a measure of the mind 
of an ordinarily educated American. In a medico-legal point 
of view this question of intelligence is a most important one, 
and one which from its very terms can receive no general solu- 
tion. Each case must be judged of by itself after a careful 
examination. 

The causes of aphasia may be studied under two heads : 

1st. The anatomical cause. In the majority of cases, espe- 
•cially such as occur in persons past the prime of the life, apo- 
plexy must be held accountable for the lesion. This effusion of 



32 THE APHASIA QUESTION. 

blood may be small, producing only amnesia of speech and writ- 
ing, or the laceration of brain substance may be of such extent 
as to cause hemiplegia, and in some cases to be followed by 
death. In younger persons, if a valvular cardiac lesion be diag- 
nosticated and if the general health be such as to exclude athe- 
roma of the arteries, then plugging (embolism) of one of the 
branches of the circle of Willis hafs probably occurred. It is sup- 
posed by some that syphilis may lead to a roughening of the in- 
ternal coat of the arteries, and thus produce coagulation of the 
blood (thrombosis) which shall deprive a part of the brain of its 
proper supply of food. Syphilis may, in still another way — the 
pressure of an internal node upon the brain — develop aphasia. 
Wounds of the skull and cerebral substance occasionally lead 
to the same result. Secondary pysemic abscesses might produce 
the symptom, though no case thus caused has yet been reported. 
And, lastly, it must not be forgotten that aphasia without lesion 
of the cerebral substance has been reported in three instances : 
by Gairdner,* by Hillairet, t and in Case L of this paper. What- 
ever may be said of the latter case, that related by the distin- 
guished Glasgow professor must be accepted. It may be added 
that at the Societe d' ' Antliropologie in 1861, M. Kufz stated that he 
had observed aphasia supervening on the bite of a certain snake 
(serpent fer-de-lance). This loss of speech was sometimes instan- 
taneous, but usually it came on in a few hours after the accident. 
In persons who did not die poisoned, the aphasia persisted indef- 
initely, and it seemed to be entirely independent of the location 
of the bite. Intelligence was in all cases preserved, and the 
affected persons went about their ordinary occupations in silence. 
Where all this occurred was not stated. And M. Brown-Sequard 
has record of more than one case of aphasia due to peripheral 
irritation, and in which no cerebral lesion could be discovered 
after death. 

2d. Psychologically speaking the difficulty may be of various 
nature. In order to enter into the necessary details with clear- 
ness, let the following be accepted as hypothetical elements of 
language. To support this division would require greater space 
than can be allowed to a mere report. Suffice it to say that it is 
an extension of the views of speech held by Fournie^: and Wil- 

* Glasgoic Med. Journal. June, I860. 

f Journal de Medecine MentaU. Sept. et Oct., 1865. 

X Phys. de la Voix et de la Parole. Paris, 



THE APHASIA QUESTION 33 

bur. * The elements, then, that enter into the physiological 
growth of language are as follows : 

a. The sounds or signs, representing or suggesting an idea, 
transmitted to the sensorium by means of the ear, the eye, or the 
touch. 

b. The formation of the idea (most probably in the gray cor- 
tical matter). 

c. The memory of the words or signs necessary to express this 
new-born idea. 

d. The willed movements of various parts ; organs of speech 
for phonation, of the hand for writing, and of numerous muscles 
for gesture. 

e. The production and modulation of sound. 

a. The sounds or signs. The study of this division may with 
propriety be omitted, as not coming within the scope of this 
paper ; though in the aphasiform troubles of idiots f and deaf- 
mutes it plays an important part. 

b. The formation of ideas. Is it diminished, and are trains of 
thought imperfect in aphasics? This important question has 
received various answers. In examining patients with complete 
aphasia and hemiplegia, it has appeared to most observers that 
this part of mental action had considerably deteriorated. But 
it must be borne in mind that the communication between the 
physician and the patient is in these cases very imperfect, so 
that even if there were no testimony rebutting this opinion, it 
would be well to take it with caution. But there is testimony of 
the most valuable kind in the shape of accounts given of - their 
own cases, by two distinguished members of the profession. 
Let the medical witnesses speak. Prof. Lordat, of Montpellier 
(France), a most attractive extemporaneous speaker, and an 
excellent teacher, was deprived of articulate and written lan- 
guage for several months in the year 1828. He says : " I thought 
of the Christian doxology, 'Gloire au Pcre, au Fits, et au Saint- 
Esprit? and it was impossible for me to remember a single word 
of it." Again : " I could think upon abstract matters, combine 
and distinguish them, without having any words to express them, 
and without paying the least attention to expression. I expe- 
rienced no embarrassment in thought. For many years accus- 
tomed to the trying duties of public teaching, I congratulated 

'"" Papers on Aphasia, already cited. f Wilbur. Op. cit. 

3 



34 THE APHASIA QUESTION. 

myself upon being able mentally to arrange the various proposi- 
tions of a lecture, and to change the order of ideas at will." 
Trousseau, not willing to abandon the philosophic doctrine that 
words are indispensable instruments of thought, expresses the 
opinion that Lordat must have deceived himself. A professor of 
the faculty of Paris, confined in bed on account of an injury, was 
reading the Entretiens Litteraires, of Lamartine, when, without 
other warning, he noticed that he did not fully understand the 
sense of the text. He dropped the book a moment, then tried 
again to read, and once more observed that he understood noth- 
ing of the light and entertaining pages. Trying to speak, he 
found that he could not utter a single word ; he attempted to 
write, and failed as completely. Thoroughly alarmed, he pro- 
ceeded to an examination • of his body ; moving his tongue and 
limbs, he came to the conclusion that there was no paralysis. 
Lastly, he entered into a mental speculation as to what portion 
of his brain might be damaged. Now, M. Trousseau attempts to 
show that because he could not understand the Entretiens, the 
professor's intellect was unsettled. This can hardly be admitted, 
for it will be found on reflection that the complete amnesia of 
words would produce a like result. This valuable case is strong 
against the validity of the reading test in cases of aphasia. 

c. The memory of words and signs is an element that is of 
external origin and artificial formation. Its development varies 
in different men speaking the same language ; that is to say, 
that some minds seem to have a capacity for a much larger 
vocabulary than others, the training and education having been 
similar. There is also a difference between the educated and 
the ignorant in this respect. Some men (Cardinal Mezzofanti, 
for example), have acquired the vocabularies of more than sev- 
enty tongues. Contrarily, Kasper Hauser, the imprisoned boy 
of Niiremburg, at the age of sixteen, knew but the words mann 
and ross ; the only formed stimuli his sensorium had ever 
received ; and yet he was no idiot.* A patient completely apha- 
sic may be made to copy a word, but if the model be withdrawn, 
it becomes impossible for him to reproduce the combination of 
letters forming it, the written echo being put down instead. 
Again, by dint of repetition, the same patient may be made to 
repeat a word or two, but the matter thus acquired has a very 

* Copland's Medical Dictionary contains an excellent account of him. 



THE APHASIA QUESTION. 35 

slight hold upon the memory. Even when speech is almost 
entirely recovered, the affected persons are aware of the remain- 
ing blanks in their vocabulary, and will even (Graves) carry about 
a list of forgotten words to help them out of difficulty. It is 
stated that Prof. Lordat, after seemingly perfect cure, never could 
improvise, nor could he speak written lectures from memory ; he 
was forced to have his manuscript constantly before him. That 
admirable clinical teacher, M. Trousseau (whose premature death 
is mourned by the profession the world over), taught in his 
lectures upon the subject that this amnesie verbale consti- 
tuted in some cases the whole of aphasia, in others the greater 
part. 

d. The willed, co-ordinated movements required for the produc- 
tion of speech, are sometimes entirely wanting in aphasia. The 
patient makes the attempt to speak and answer, but only suc- 
ceeds in uttering his inevitable echo. At times, as before stated, 
words to the point may be forced out by exciting the emotions. 
Dr. Robertson's patient, when asked what she would do if her 
shawl were to be snatched from her, exclaimed, to the astonish- 
ment of the doctor, " police ! " This was repeatedly exemplified 
in Case III. of this report. Without leaning toward any locali- 
zation, these movements may be explained as follows : afferent 
currents, consisting of stimuli (words or signs, a) enter by means 
of the optic, auditory, or general sensory nerves, reaching in all 
certainty to the thalami optici and the corpora striata ; they are 
according to this hypothesis thence transmitted to the gray mat- 
ter of the convolution. In this gray matter the necessary purely 
mental operations (b, c, and part of d) take place, and the willed 
movements are sent back through the same track, by means of 
motor nerves, to the organs of articulation, writing and gesticula- 
tion. Now, it has been a subject of speculation whether this 
element (d) is impaired in its will part, or whether there existed 
an interruption in the conduction. This last supposition (based 
upon the fact that the white cerebral matter is almost invariably 
involved in the lesion), forms Dr. Robertson's * theory of apha- 
sia, he holding that the lesion is essentially a motor and not a 
merited one. Prof. Lordat t had such a theory in view when he 
ascribed the loss of language to an " asynergie verbale." Drs. 

* Robertson. Journal of Mental Science ; Jan., 1867, p. 503. 
t Lordat. Analyse de la Parole, etc. Montpellier, 1843. 



36 TEE APHASIA QUESTION. 

Letourneau * and Cerise f believe that the condition in ques- 
tion may be due in great part to a lesion of transmission. 

e. The production and modulation of sound need not be more 
mentioned in this connection, as it is evident to any one who has 
seen a case of aphasia that the patient's larynx and vocal cords 
perform their functions perfectly. This statement is not in- 
tended to apply to such modulations as are required for intricate 
musical vocalization, though no case has been reported in which 
laryngeal musical language has been lost, yet such a loss may, 
a priori, be expected to occur. 

After this cursory review of the pathology of aphasia, the ques- 
tion of localization presents itself ; a question which has recently 
been discussed in France, more especially, by the most eminent 
men, and with great vehemence. As the numerous papers on 
the subject have not done much toward the settling of the vexed 
points, it will only be necessary to examine the facts brought 
forward and the arguments used in the two Parisian societies ; 
and as the object of this report is merely to state the progress 
made in the study of their condition, this examination will be 
brief and will involve no criticism. The first discussion occurred 
in the " Societe oV Anthropologic " in 1861 ; the second, in the Im- 
perial Academy of Medicine in 1865. For greater precision 
the two divisions of the question will be treated of separately. 

1st. The psychological proposition : there does exist a faculty 
of language, was announced by Gall \ in 1809 ; he following in 
this the authority of philosophers of the preceding century ; it 
was a part of his celebrated hypothesis, phrenology. It is 
remarkable that though his doctrine as a whole was immediately 
attacked, yet this particular proposition was accepted by quite a 
number of the eminent members of the profession. In 1825, 
Bouillaud§ acknowledged that he recognized a faculty of lan- 
guage, and he brought forward a large number of cases to prove 
that this faculty was located just as Gall had indicated. The 
leading medical minds being at that time engaged in the develop- 
ment of new-born pathological anatomy, this psychological aspect 
of the subject did not receive the attention it deserved. But in 
the Societe oV Anthropologic || in 1861, after a rather adverse report 

* L'Union Medicale. 18 Mars, 1865. 

f Journal de Medecine Me?itale, p. 229. Paris, Sept., Oct., 1866. 

X Recherches sur le Systeme Nerveux. Paris. 

§ Traite de l'Encephalite. Paris. 

1 Bulletin de la Soc. d'Anthropologie. Tome II., 1861. 



THE APHASIA QUESTION. 37 

by M. Lelut, on a paper by G. Dax, Bouillaud again boldly pro- 
claimed himself a follower of Gall ; stating that while he was not 
prepared to feel bnmps, yet he believed the principle of locali- 
zation of the faculties to be a great truth. This was followed by 
a powerful debate. Auburtin elaborately supported Bouillaud, 
while Lelut took strong grounds against phrenology in any form, 
saying that he was not willing again to take up arms against an 
error which he had helped to destroy twenty-five years pre- 
viously. Gratiolet, one of the greatest of French neurologists, 
followed in a very brilliant and forcible argument, principally of 
an anatomical nature. He stated that while no positive proofs 
could be adduced of the non-existence of faculties as distinct, 
independent portions of mind, yet the very complex nature of 
these so-called faculties, their mutual connection and dependence, 
and the observation of the development of the intellect, all tended 
to show that the mind was a whole, a soul, manifesting itself in 
protean ways by means of, or through organs. Phrenologists 
having asserted the affirmative, their opponents were laboring 
under the disadvantage of having to disprove their proposition. 
If language could be localized, then the other so-called faculties 
might as well be, and the human mind would take at once a 
giant stride into materialism. He concluded with a brilliant 
protest against the attacks made upon the mental unity of man. 

In the Academy of Medicine, during 1865,* Bouillaud, power- 
fully aided by Broca, supported phrenology once more ; the 
debate this time being upon the last and boldest venture of these 
two distinguished men, viz. : the location of language in the 
posterior part of the third frontal convolution of the left hemi- 
sphere. Trousseau, while citing cases opposed to this hypothe- 
sis, certainly seemed inclined to favor it. The leading physicians 
to the insane, however, Parchappe, Cerise, Baillarger, brought 
forward many opposing cases and stoutly maintained the unity of 
the mind. Fournie in his late work,f utterly rejects the idea of 
the existence of faculties and their localization. Vulpian X h as 
added the weight of his great authority against any such modifi- 
cation of phrenology. In this country, the only writer on the 
subject, Dr. Wilbur, is opposed to it as well. 

2d. The anatomical proposition : As before stated Broca's an- 

* Archives Generales de Med. 1865, Vols. I and II. 
f Physiologie de la Voix et la Parole. Paris, 1866. 
% Lecons de Physiologie du Systeme Nerveux. Paris, 1866. 



38 THE APHASIA QUESTION. 

nouncement was met (as indeed Bouillaud's and Dax's had been 
before) by numerous negative cases ; and when the last-named 
discussion took place, carefully made autopsies since 1861 had 
furnished (Trousseau) fourteen cases for and eighteen against the 
third convolution view. Various objections were offered to the 
correctness of these negative examinations, but in the last two 
years quite a number of others have been made by the most 
reliable observers, and the cases must be accejoted. It will be 
shorter and clearer to treat of the three localization theories in 
a semi-statistical manner, though it must be acknowledged that 
the figures given are far from complete, especially those in the 
negative. 

a. Gall's and Bouillaud's localization in the anterior lobes. 
The number of cases favoring this view has reached (as this class 
includes the other two) five hundred and fourteen ; those against 
only thirty-one," but this includes four such remarkable instances 
of injury to the brain without loss of language as to require 
quotation at length. Professor Bigelow, of Boston, has reported f 
a case which occurred in the practice of Dr. Harlow, of Cavendish 
("Vermont). On the 13th of September, 1848, the foreman of a 
mine, a young and healthy man, was standing over a newly laid 
blast with a tamping-iron in his hands. This was an iron bar, 
pointed at one end (which end was directed upward), one hundred 
and ten centimeters in length, three centimetres in diameter, and 
weighing six kilogrammes. Thinking that the blast had been 
properly covered with sand, he struck it a blow with the round 
end of the bar, when a spark flying from the rock ignited the un- 
covered powder, producing an explosion which drove the tamp- 
ing-iron completely through his skull. The pointed extrem- 
ity entered at the angle of the lower jaw, on the left side, 
passing upward and a little inward, it escaped in the neigh- 
borhood of the anterior fontanelle junction. The iron was 
found, covered with blood and cerebral substance, at a distance 
of several meters. Shortly after this he sat up and talked 
while on his way home in a wagon. When seen by Dr. H. the 
patient was cool and rational, describing the occurrence accu- 
rately. The direction of the wound was verified by the intro- 
duction of the finger into both openings ; and from the place of 

- The writer is informed by Dr. Brown-Sequard that this number might be con- 
siderably increased from his own and other unpublished cases. 
f American Journal of Med. Sciences, July, 1850. 



THE APHASIA QUESTION. 39 

exit portions of the frontal and parietal bones were removed, 
leaving an opening nine centimeters in diameter. During the 
progress of the case the patient retained full command of 
speech, and though at times drowsy, yet he was always rational. 
On October 11th, being asked how long had elapsed since the in- 
jury, he instantly replied, " Four weeks this afternoon, at half 
past four o'clock." Kecovery was perfect about the end of No- 
vember, but the sight of the left eye was lost. In January, 1851, 
he came to Boston and was shown to the medical class by Dr. 
Bigelow. He was at that time in perfect health. It may be 
well to mention that this case is supported by the affidavits of a 
number of reliable and intelligent persons. In the same peri- 
odical for January, 1850, is related a case by Dr. Detmold, of 
New York, in which, after severe injury to the frontal region and 
secondary suppuration, the anterior left lobe was incised freely 
twice at least. No difficulty was observed in the speech, and the 
patient talked a good deal when not comatose. In the debate 
at the Anthropological Society, Gratiolet detailed the following 
case from the service of M. Berard. A man was wounded in the 
forehead by the explosion of a mine ; on being picked up, the 
patient was rational, and gave an account of the accident. He 
walked to the hospital, and when seen there by Berard he had 
no paralysis and spoke well. Death took place in twenty-five 
hours, and the autopsy showed both the anterior lobes reduced 
to a jelly and penetrated by spicula. Trousseau * gives a case no 
less important observed by M. Peter at the military hospital of 
the " Gros-Caillon ; " that of a cavalryman who, while intoxicated, 
fell from his horse striking upon the occipital region and fract- 
uring the skull. In the hospital this man developed the wildest 
delirium, swearing most energetically, and carrying on conver- 
sations with imaginary . persons. Thirty-six hours later death 
supervened, and a post-mortem examination showed that the 
extremity of both anterior lobes had been disorganized by contre- 
coicj?. The writer has been kindly told t of a case very recently 
observed by Dr. Stokes, of Dublin, in which, for suicidal pur- 
poses, three small balls had been fired from a pistol' into the 
temporal region. The frontal bone was very extensively fract- 
ured, the anterior lobes lacerated, and at length nearly de- 



* Clinique Medicale, t. ii. p. 610. 

f Verbal Communication, by Dr. Brown-Sequard. 



40 



THE APHASIA QUESTION. 



stroyed by inflammation, and yet no aphasia manifested itself. 
Coma came on only in the last days of life. 

b. The hypothesis of the doctors Dax, father and son (accepted 
by Bouillaud and Auburtin in 1861), of localization in the left 
anterior lobe. The following table contains the cases that were 
collected for the purpose of sustaining this view, and the few 
negative autopsies made recently and more particularly opposed 
to Broca : 

Question of Left Anterior Lobe. 



AUTOPSIES BY 


FOR. AGAINST. 


Marc Dax (1836) and G. Dax (Acad, de Med. 

1863) 

Bouillaud, 1848 

" 1865 

Trousseau, " (Acad, de Med.) 

Vulpian (Lecons de Phvs. 1866) . . 

New York Hospital (1830-67) .... 

Jackson, 'Richardson, A. Clark, 1866-7 

Peter Legrand, Beclard, Delpech, Berard. one 

each ........ 

Farge, Bigelow, Detmold & Stokes (one each) 


370 

85 

31 

18 

5 

2 

3 


16 
6 

5 
4 


Total 


514 


31 



c. Broca's hypothesis of localization in the posterior part of 
the left third frontal circonvolution, in the neighborhood of the 
island of Rett. The details of the two cases, and autopsies 
which gave birth to this idea, and which brought about the 
" brilliant conversion " of M. Paul Broca to the phrenological 
doctrine, are to be found in the Olinique lledicale of Trousseau, 
Vol. II., article aphasia. It is useless to reproduce them or any of 
the twelve or fifteen other cases in which this precise lesion has 
been found, but for the purpose of guiding future investiga- 
tions, the following description by Broca, of the topography of 
the part of the brain involved, may not be without interest. 

-::- « rpi ie su i cus Q f Rolando divides the anterior from the mid- 
dle lobe ; it traverses the external surface of the hemisphere 
from above downward ; starting from the longitudinal fissure to 
terminate in that of Silvius. Anteriorly this sulcus is bounded 
by the transverse frontal convolution, posteriorly by the trans- 



* Translated from Trousseau. Op. eit. 



THE APHASIA QUESTION. 



41 



verse parietal convolution. The anterior lobe thus comprises 
all that portion of the hemisphere which is (above) anterior to 
the sulcus of Rolando, and (below) in front of the fissure of Sil- 
vius. The inferior part of the anterior lobe is formed by the 
so-called orbital convolutions. The superior and lateral por- 
tions of this same lobe are made up by the proper frontal con- 
volutions. These are three in number : a superior, or first ; a 
middle, or second ; and lastly, an inferior one, the third frontal 
circonvolution. They all run antero-posteriorly, and terminate 
in the transverse frontal convolutions, of which they seem to be 
branches. The third frontal convolution is free in its posterior 
half, and is separated from the middle lobe by the fissure of Sil- 
vius, whose anterior border it forms. On account of this rela- 
tion, the third convolution is sometimes spoken of as the supe- 
rior marginal, and the first temporo-sphenoidal convolution as 
the inferior marginal. "When these two marginal convolutions 
are separated, there is perceived, at the bottom of the fissure of 
Silvius, a rather distinct eminence, from the summit of which 
start five small convolutions, or more - properly speaking, five 
straight folds, in the shape of a fan ; this is the island of Eeil, 
which is directly connected with the extraventricular portion of 
the corpus striatum." 

The next table contains only such autopsies as have been 
made with especial reference to this question, or in which the 
details given were sufficient clearly to indicate the location of 
the lesion. 



Question of Left Third Frontal Convolution. 



AUTHORITIES. 


FOE. 


AGAINST. 


Trousseau, 1865 (in Acad, de Med.) 

Peter Legrand, Beclard, Delpech, Berard, Farge, 

Jackson, Bigelow ..... 
Jackson, Richardson, Russell 
New York Hospital (1830, 1867) . 
Bellevue Hospital, Oct., 1867* 


14 

o 
o 

1 


18 

8 

7 
1 


Total 


18 


34 



The following tables, on other points, may prove of interest. 



* Case in service of Dr. A. Clark ; mentioned by permission. 



42 



THE APHASIA QUESTION. 
1. Aphasia without Pahaltsis. 



Jackson, Lond. Hospital Reports, Vol. I. 
New York Hospital .... 



Total 



10 
2 



12 



2. Aphasia with Hemiplegia. 



authorities. 


RIGHT HEM. 


LEFT HEM. 


Trousseau, 18G5 (Acad, de Med.) . 
Baillarger, later in 1865 (from Salpetriere) 

Jackson, loc. cit 

Robertson, loc. cit. ..... 

Medical Times and Gazette, Sep. 9, 1865. 
Arch. Gen. de Med. 1866, Vols. I and II. 
Austin Flint, Sen., New York Medical Record 

Vol. I 

New York Hospital, 1830-67 


125 

30 

34 

3 

2 

2 

4 
43* 


10 
1 
3 

3 


Total 


243 


17 



5. Parts of Encephalon Damaged in Aphasia Cases. 



Third Frontal Convolution on left side 

" " " right side 

Anterior Lobe of left side 

" " £ight side . 

Lateral Ventricles distended 

Corpora Striata 

Middle Lobes . . . . 

Posterior Lobes ' . . ■ » ■ 

General Softening of one Hemisphere . 

Cases of Aphasia without lesion of brain substance 

A number of cases caused by reflex action. 



19 
1 
514 
2 
2 
6 
3 
4 
2 
3 



A discussion of the evidence here presented, or the offering of 
any new theory of aphasia, would be a transgression of the limits 
of this paper. Besides, this evidence has been deemed, by high 
authorities, not sufficient to settle the question. Of course, no 
•one will deny that the coincidence of nineteen cases in favor of 
Broca's view is a most remarkable one, and that it must mean 
something, if it does not signify that the faculty of language is 
located in that famous third convolution. To some minds, the 
cases related, of great injury to the anterior lobes, supported by 
such names as Bigelow, Gratiolet and Stokes, will at once settle 



THE APHASIA QUESTION. 43 

the question in the negative. And many, no donbt, will be 
inclined to Brown-Sequard's reflex theory, especially if the expe- 
rience of M. Rufz as to the effect of a poisoned peripheral injury 
should be confirmed. 

All this can only be settled, if at all, by observation. More 
cases are wanted, and these must be more perfect than any hith- 
erto reported. It is the principal object of the writer to provoke 
a thorough study of cases by every member of the profession 
who shall have the opportunity. Publish the cases as soon as 
complete, and send (if living in the country) the specimens 
to the pathological society of one of the great cities for 
presentation. In making the autopsies it is important that 
the state of the heart and arteries should be ascertained, 
the branches of the circle of Willis being minutely exam- 
ined before any incisions are made into the brain. The micro- 
scope should be used to discover the state of the histological 
elements or the presence of pathological ones ; and especially, 
if the third left frontal convolution does not appear altered to 
the naked eye, ought its substance to be examined with a 
low objective at the least ; and in all cases it is highly desir- 
able that the body should be opened within twelve hours after 
death, to avoid the occurrence of too great cadaveric change. 
In carrying on such investigations two things should be kept in 
mind. Firstly, the condition necessary to the establishment of 
a theory of aphasia, including localization, as- laid down by 
Fournie : a. to find at what part of the encephalon intelligence 
(the soul) acts upon nerve fibres to excite the movements of 
speech, b. To indicate the seat of perception of the sound — 
speech, c. To determine the anatomical connections by which 
our perceptions in general act upon the sound — speech, to bring- 
about its reproduction in the sense of hearing, or to provoke the 
movements peculiar to it (the* sound — speech).* And secondly, 
the warning words with which the late lamented Gratiolet closed 
his argument in the Societe cV 'Anthropologic : " I do not hesitate," he 
said, " to- conclude that all schemes of localization hitherto pro- 
posed are without foundation. These are, doubtless, great ef- 
forts — Titanic efforts. But when from the top of such a Babel 
we attempt to seize on Divine truth, the edifice crumbles." 

* Which last proposition evidently refers to internal, unspoken language. 



44 THE APHASIA QUESTION. 

CASES IN WHICH APHASIA OCCURRED WITH RIGHT 
HEMIPLEGIA.* 

I. E. S., aet. 27, seaman, admitted February 10, 1866. The history of case 
was not fully recorded. On admission, he presented hemiplegia on the left 
side of body which had lasted four weeks, and of which he was getting bet- 
ter. Speech and intelligence were perfect. February 27. — Yesterday morning, 
patient remarked that he was nearly well. In afternoon the nurse says he 
mumbled and talked queerly. This morning he presents complete aphasia. 
At the visit he was sitting up in the bed looking intelligent but surprised and 
annoyed at his total inability to find words ; this annoyance he expresses by 
appropriate gestures. There is no paralysis of right side, and yet the power 
of expressing ideas in writing is lost ; cannot even write his own name, Ed- 
ward. Late to-day, he uttered one word. February 28. — This morning dis- 
tinct though slight paralysis and anaesthesia of right side of body are found ; 
and there is some difficulty iu swallowing. The aphasia is unmistakable, 
there being no lingual palsy and no impairment of intellect ; can't shut his 
eyes. March 1. — Hemiplegia on right complete save a little motion in leg. 
Eyes wide open. Ordered iodide of potassium .60 four times dairy, and 
nourishing food. March 6. — Last night spoke a few words quite distinctly ; 
now takes food better. About this time, patient contracted typhus fever and 
had a pretty smart attack, with a few shallow bed-sores on sacrum. During 
the height of the fever (treated with infus. serpentariae, spongings, fresh air 
and stimulants) the paralysis disappeared in part and his vocabulary increased 
notably. Though no mention is made of the fact, the writer is confident that 
the eyelids were closed voluntarily during the intercurrent attack. During 
convalescence, the motion of the right side became very free, the anaesthesia 
disappeared, and speech gained daily. April 9. — Note is made that patient 
sits up; bed-sores are healed; he speaks well and moves limbs freely. 
Uses faradization, and strych. et ferri citras .12 t.i.d. May 1. — Is dis- 
charged w r ell, with the exception of a little embarrassment in motions of right 
arm. 

II. W. H., aet. 33, seaman, admitted February 26, 1867. On the 19th inst., 
while sailing from Richmond, Va., to this port, a few minutes after eating 
breakfast, he felt a little dizzy and became aware of loss of power in right 
half of body ; no loss of consciousness ; friends did not remark defect in speech. 
He walked to the ward ; the leg had recovered, the grasp of the hand being 
feeble, however. The face was drawn to the left and there was no anaesthesia. 
He talked generally as well as men of his class ; but on direct questioning, a 
curious partial amnesia was discovered. He did not recall his name, his age, 
nor did he remember whence he had sailed, and by which river he came 
(though he had been in that trade for years). He retained almost all words in 
common use. It is to be regretted that the power of writing was not tested. 
On the third day after admission (Feb. 29), he told us his name spontaneously, 
and not only said he came from Richmond by way of James River, but he was 

* In the period from 1830 to 1867 there were entered in the case-books fifteen 
cases of right hemiplegia without loss of speech. 



THE APHASIA QUESTION. 45 

able to speak of the points of interest along that stream, Butler's canal, etc. 
He had, therefore, completely recovered command over the stock of language 
used in his sphere of life. As to the probable lesion in this case : he bore 
no signs of premature decay, and at his age, disease of the vessels of the 
brain might consequently be thrown out; he had received no injury whatever; 
but he stated that three years previously he had suffered from sub-acute artic- 
ular rheumatism. He cannot be made to recall any heart-symptoms, either 
pain or palpitations. On examination, however, a slight alteration of both 
sounds of the heart at the base is found. The first sound is very slightly pro- 
longed, and the second has lost its sharp definition. A minute embolism is 
therefore probable. Urine normal. March 9. — He has had a little strych. et 
ferri citras, and is to-day discharged, cured. 

ni. A. O'B., set. 28, a single woman, admitted December 28, 1866. Patient 
has had pretty fair health until the end of November last, when she had an 
attack of "bilious fever " (?) lasting three weeks. On the morning of Sunday, 
December 9, being convalescent, while her sister was, 9 a.m., putting clean 
linen on her, she suddenly exclaimed that she had a pain in the stomach and 
wanted a drink. In less than five minutes afterward it was noticed that her 
right side was palsied and that she could say nothing. It seems that 
she was then unconscious for five or six days, but whether complete coma 
existed is not certain ; since that sixth day she has been intelligent. From 
that time her general condition became pretty good ; her appetite increased 
and digestion was well performed. The sphincters acted normally; the face 
was drawn to the left ; she complained of severe pain in top of head ; a bed- 
sore formed upon right side of sacrum, and another upon right outer malleo- 
lus; and she acquired a few words, "no" and "darling." On admittance, 
the following points were noted : there is no motion in the right side of the 
body ; sensibility of skin is not materially affected ; the face is drawn to the 
left side ; the tongue, wdien portruded, points to right ; the jmpils are nor- 
mal in size and sensibility. Her intellect seems to be in perfect order ; mem- 
ory alone being disordered in its relation to language. As concerns the 
three elements of the functions of language. 1st. Speech proper is substan- 
tially lost, all that remains at her command being the w r ords "dear," "dar- 
ling," "yes," "no," and "I couldn't." Articulation itself is perfect. 2d. 
It is not possible to ascertain the existence of the power of written language 
as paralysis affects right hand. 3d. Gesture is completely lost, though her 
eyes show impatience and grief, yet her left hand and shoulders are not 
used to express these feelings. There is no palsy of pharynx or of tongue as 
a whole. Bed sores are improving. Within a week after admission she 
acquired a few more words, "doctor," "good morning," and "Julia." 
Great efforts were made by physicians and nurses to teach her by repetition 
of words and by a sort of objective system, but in vain. Occasionally, new 
words, chiefly emotional phrases, w T ould be forced from her by joy or sorrow 
or sudden questioning. She hummed quite a number of tunes as well as 
before illness. She also began to use the left hand in gesture. January 20, 
1867. — She cannot say her own name, though she is angry at being called 
Brown or Smith; her general vocabulary has not increased. If asked for a 
thing she points to it or brings it. Her general health is better and the bed- 



46 THE APHASIA QUESTION. 

sores have healed rapidly. Face is less distorted, leg moves a little, but arm 
is useless. The electrical condition of the muscles (sensibility and excitability) 
is good. Takes iron and strychnia and the iodide of potas., with good food 
and faradization of muscles. Walks a little ; speech same ; mind not so bright. 
Discharged by request. 

IV. E.B., set. 28, seaman, admitted Nov. 23, 1863. After severe vomiting 
on the 21st, is said to have gradually become hemiplegic on right side. No 
details of attack. On admission, is deprived of motion on right side ; mouth 
a little drawn to left side ; pupils natural ; "though patient cannot speak, 
and cannot or will not make signs, lie moves his eyes in a manner that indi- 
cates intelligence." November 28.— Since last, three dislocations of jaw have 
taken place ; they were easily reduced. Patient now utters a few simple 
words, and gains motion. December 26. — Patient now walks tolerably well, 
and speaks readily. Has had no medicines excepting occasional laxative. 
Discharged cured. 

V. C. O., set. 50, married woman, admitted July 9, 1864. No history can 
be obtained from patient. Friends state that four days ago she had an " in- 
ward spasm, " since which she has been palsied, and has lost her speech. On 
admission, there is partial paralysis of right side, with slight anaesthesia ; 
mouth is slightly drawn to left side, but tongue protrudes straight. Speech 
much impaired. Ordered blister to back of neck, and potass, iodide .60 
t.i.d. August 18. — Has regained use of limbs, but is merely possessed of a 
few words. She finds it impossible to express her ideas. Discharged 
cured. 

VI. F. M., set. 28, seaman, admitted December 10, 1862. On 8th Decem- 
ber, paralysis of right side of body, with complete loss of speech came on ; 
no details. On admission, patient is perfectly conscious, and has recovered 
some speech. There is entire loss of motion on right side ; tongue does not 
deviate. December 15. — Patient got a bronchitis, which to-day proved fatal. 
No autopsy allowed. 

VII. S. F. L., set. 48, merchant, admitted January 17, 1862. Patient was 
brought in about -midnight, from No. 121 Greene street, where, during the 
act of coition, he was attacked with palsy. On admission, there exist com- 
plete paralysis and anaesthesia of right half of body ; tongue deviates to right. 
Patient appears to understand everything, but cannot answer, excepting by 
saying "I can't speak," and by signs expressive of despondency. January 
20. — Has improved somewhat in speech. Has taken good food, and tin ct. 
aconiti .20 t.i.d. March 4. — Now walks across room pretty well ; has still 
anaesthesia ; speaks well, but deliberately. Cured. 

VIII. J. H. H., set. 30, grocer, admitted July 17, 1861. Three years ago 
patient had an attack of apoplexy (no particulars), from which he slowly re- 
covered, but has retained a feeling of vertigo. Eight days ago second attack 
came on suddenly, with coma, lasting twenty-four hours. On recovering, it 
was noticed that he answered slowly, imperfectly, and not to the point. On 
admission, entire right side is paralyzed, and sphincters relaxed. July 27. — 
Has some motion in right side, and no longer passes faeces and urine involun- 
tarily ; speech the same. Has had a blister between shoulders, and potass, 
iodide .60 t.i.d. August 24. — Since last, has had specific iritis (had chancres 



THE APHASIA QUESTION. 47 

six and eight years ago), and was treated with mercury. Can now walk to 
window. September 7. — Patient is completely cured. 

IX. C. W., set. 19, single woman, admitted January 15, 1860. Two days 
ago had attack of paralysis, affecting right side of body and face; "speech 
is slightly affected." Has had syphilis. May 29. — Under tonics has im- 
proved much ; walks pretty w T ell, but cannot raise arm. Discharged relieved. 

X. A. C. S., set. 45, merchant, admitted April 20, 1859. Yesterday, while 
walking, was struck with palsy. On admission, has recovered from coma; is 
completely paralyzed on right side ; recognizes his friends, but cannot pro- 
trude tongue or speak. April 23. — Is able to protrude tongue, and says a few 
words; is perfectly rational. June 16. — Patient has improved in every way 
under tonics, and is discharged relieved. 

XI. D. H., set. 52, ship-steward, admitted September 1, 1858. Patient was 
paralyzed in April last. Has been healthy and temperate. Last March had 
acute rheumatism. On admission, is suffering from loss of power on right 
side ; face paralyzed on left ; patient can hardly articulate, and cannot give 
history; laughs immoderately. September 15. — Symptoms of cerebral soften- 
ing showed themselves, and have rapidly progressed ; died to-day. No au- 
topsy. 

XII. P. P., set. 38, weigher, admitted June 9, 1858. Is brought in after 
having had a fit. Right side of bod}*, and left side of face are paralyzed. 
Notes say there is also "rjaralysis of tongue." June 27. — Discharged at 
request ; not improved. ' 

XIII. Unknown man, admitted October 8, 1857. Brought in comatose. 
October 9. — After stimulating enemata and sinapisms has rallied. Paralysis 
of right side, without ansesthesia ; is conscious, and understands questions, 
but makes no reply. October 11. — Died comatose. Autopsy showed left 
lateral ventricle filled with a recent clot. No details. 

XIY. W. D., set. 65, merchant, admitted 25th March, 1857. Received 
nearly comatose, with hemiplegia of right side of body and face; left pupil 
dilated. March 26. — Rallying. "On being questioned, he seems to under- 
stand what is said to him, and attempts to answer it. The first two or three 
words are evidently in reply, the rest incoherent." Urine and fseces passed 
in bed. April 15. — Died, but no autopsy allowed. 

XY. J. H. C, set. 55, clerk, admitted January 22, 1857. Two hours ago 
he was seized with hemiplegia of right side. On admission, paralysis is com- 
plete, face drawn to left; pupils are natural ; " speech mumbling." He ap- 
pears to understand what is said to him, and tries to auswer; has control of 
sphincters. February 12. — Patient has since had an attack of facial erysipe- 
las, but has steadily improved. Discharged relieved. 

XYI. M. W., £2t. 16, single, servant girl, admitted September 25, 1856. 
Patient has never menstruated, but has had palpitations and dyspnoea on ex- 
ertion, together with tolerably regular monthly epistaxis. Never had rheuma- 
tism. Three days ago (after violent headache and lighter epistaxis than usual) 
her friends noticed that she was palsied on the right side; and in p.m. of same 
day she became comatose, and remained so until to-day. t On admission, pa- 
tient is conscious ; has partial paralysis of right leg, in right arm it is com- 
plete ; facial palsy on right side ; pupils regular. Patient has lost power of 



48' THE APHASIA QUESTION. 

articulating words, and merely utters a harsh cry when addressed. A blowing 
sound is heard all over precordial space, loudest at apex ; impulse of heart 
is forcibly felt in fifth intercostal space, nine centimeters from median 
line. Mamma} not developed. October 3. — Patient has improved; face is 
nearly straight, and to-day she utters a few words. October 10. — Had been 
gaining steadily, when at 2 p.m. she had a convulsion, became comatose, and 
at 9 p.m. died. Autopsy, fifteen hours post mortem. Heart weighed five kilos. 
Aortic valves were healthy; mitral covered with vegetations; brain substance 
healthy. A clot is found distending the left lateral ventricle, right empty. 
At base, a more recent large clot is discovered. No mention of state of arte- 
ries. A recent corpus luteuin found in ovary. 

XVII. J. D., a?t. 52, omnibus driver, admitted April 9, 1855. While 
driving, a couple of days ago, was suddenly struck with paralysis. On 
admission, there is complete loss of motion and sensation on right side of body, 
and left side of face ; patient cannot speak ; heart healthy. May 4. — Dis- 
charged relieved. 

XVIII. F. F., admitted June 29, 1854, in a state of delirium. June 30. — 
To-day patient is rational, but can give no account of himself, as he can artic- 
ulate but few words. There is complete paralysis of right arm, and partial 
of leg; face paralyzed on same side; right pupil larger. July 11. — It is now 
learned that two months ago patient received a blow on the head, and sud- 
denly became palsied. Is now much better. Eloped relieved. • 

XIX. E. Van H., admitted May 23, 1854. Has had poor health of late. 
Yesterday he suddenly lost power of speech, and became paralyzed in right 
arm. On admission, face is drawn to one side; right hemiplegia; and patient 
is speechless, but rational. June 1. — Died. Autopsy showed considerable 
serum under arachnoid, and in ventricles; brain substance considerably soft- 
ened; no details. Some ascitic dropsy; heart not examined. (This autopsy 
is not included in tables.) 

XX. S. C, set. 29, seaman, admitted April 4, 1856. In January was sud- 
denly palsied while going from a warm into a cold room. On admission, had 
a little use of right side; face paralyzed on right side; patient does not speak 
as plainly as he did before this attack. April 17. — Discharged by request. 

XXI. C. W., set. 33, mechanic, admitted March 13, 1855. On March 9, 
was found insensible, but recovered in a day or two. On admission, there is 
paralysis of right side of body and face ; sensibility on that side is somewhat 
impaired ; right pupil dilated. March 20. — Examination shows increased dull- 
ness over heart, a harsh systolic murmur at apex. Has had rheumatism. 
June 30. — Has gradually improved. Now walks about grounds, and utterance 
is much better. July 9. — Discharged cured. 

XXII. K E., a3t. 6G, seaman, admitted July 16, 1851. Five weeks ago, 
after lying on deck of a steamship in the sun, he woke with palsy of right 
side. On admission, right arm is nearly useless, leg not so much affected ; no 
anaesthesia. " Speech is very much affected." Controls sphincters. Ordered 
tonics and good food. December 1. — Has regained considerable power. 
May 14, 1852. — Is sent out relieved. 

XXIII. Ann B., a?t. 55, widow, admitted October 18, 1850. Was well 
until six months ago, when she began to suffer from severe pain and tenderness 



TUB APHASIA QUESTION. 49 

iu right side of head; some two months later this occupied both sides. Six 
weeks ago, while in church, she was seized with a general palsy. Her con- 
sciousness did not leave her, but she lost the power of speech and motion ; 
she cannot say for how long a time. Has since had two similar attacks of 
same nature. Denies having had syphilis, but she has had much rheumatism 
in long bones. On admission, no mention in notes of paralysis or loss of 
speech. TVas leeched and salivated. February G, 1851. — Has greatly im- 
proved; hardly any pain. April 2. — Sent away disorderly. 

XXIV. Ellen M., set. 26, single, cook, admitted January 20, 1850. One 
week ago, while crossing a street, she fell down in an apoplectic (?) attack, 
but was soon able to get up, walk home, and resume work. Three days since 
she was troubled with numbness, and then had a seizure like the first, which 
left her with right hemiplegia. On admission, there is complete palsy of 
right side ; patient unable to speak. January 22. — Heart healthy ; still can't 
speak. Leeches to temples and tartar emetic ad nauseam. February 1. — 
A little motion in right leg, and she speaks a little. Of late has had 
strychnia .008 bis die, with electricity to affected limbs. Discharged re- 
lieved. 

XXV. M. T., set. 30, seaman, admitted June 6, 1849. Three days ago was 
struck on head by a falling mast. On admission is paralyzed on right side, but 
is wide awake. Is obstinately constipated. At last (after many other med- 
cines), four drctps of croton oil have produced a moderate stool. Ordered 
calomel to affect system. Nov. 12. — After mercurial course he improved until 
middle of July ; since no change ; "talks incoherently." Discharged. 

XXYI. C. L., set. 60, admitted August 6, 1848. Has just come from 
Europe in steamer. Is hemiplegic on right side ; is very stupid, but not 
delirious. Aug. 15. — Is not as strong as on admission. Is unable to articu- 
late with any distinctness. 27. — Died. Autopsy, ten hours post-mortem, 
revealed a cyst containing 65.ee of serum in right hemisphere over ventricle, 
but unconnected with it. Other organs not examined. 

XXVII. A. L., set. 40, civil engineer, admitted April 12, 1848. Has been 
a pretty hard drinker for two or three years. Four days ago had an apo- 
plectic fit with coma for half an hour. On admission, complete paralysis and 
anaesthesia of right side ; all power of articulation lost ; ordered strychnine 
.004 t.i.d. June 13. — For a month has been able to walk in garden with 
a cane ; speaks more distinctly. Discharged relieved. 

XXVIII. A. B., set. 70, seaman, admitted April 9, 1848. Four days ago 
had a sudden loss of power on right side ; has had several such attacks 
before. On admission, there are paralysis and ansesthesia of fight side ; 
patient is obliged to articulate slowly. 15. — In spite of electricity and strych- 
nia he died to-day. Autopsy ten hours after death showed serous effusion 
under arachnoid and in left ventricle ; much softening of left hemisphere. 

XXIX. P. B., set. 17, clerk, admitted -Sept. 17, 1847 ; two weeks ago was 
noticed to be du}l ; one week ago, after a fit, was found to be palsied. On 
admission, has paralysis (no ansesthesia) of right side of body and face ; 
speech is muttering and unintelligible ; face rather stupid. Dec. 4. — Has had 
tonics, strychnia and electricity ; can use arm and leg ; no mention of state of 
speech. Discharged cured. 

4 



50 THE APHASIA QUESTION. 

XXX. P. N., set. 52, shoemaker, admitted May 22, 1846. Six weeks ago, 
after a fit of anger, patient had an attack of apoplexy. On admission, right 
side of body is recovering from paralysis ; patient "speaks with difficulty." 
June 19. — Now walks in yard ; discharged relieved. 

XXXI. C. R, set. 53, seaman, admitted February 21, 1846. For a month 
has had pain in back of head ; on trying to rise, ten mornings ago, he found 
his right side paralyzed and speaking difficult. 25. — Feels better than on ad- 
mission ; heart is a little large, no murmurs ; has some pain over left lobe of 
cerebellum ; does not speak as well as usual ; no fever. March 2. — Has lost 
power of speech almost entirely ; the left side of body is now paralyzed more 
than right, which still improves. 4. — Walks a little and speaks better ; has 
been cupped, and had low diet. May 7. — Has much improved ; speaks 
fairly ; electricity daily applied. July 16. — Discharged relieved. 

XXXII. Mary Y., est. 56, married, admitted July 14, 1846. Four weeks 
ago, after a fall on left side of head, she became unconscious ; on coming to, 
was found hemiplegic on right side. On admission is paralyzed on right side 
of body ; tongue points to left ; "she cannot give a good account of herself." 
23. — Is discharged as improper object. 

XXXIII. John H., admitted Nov. 27, 1845. Yesterday was attacked with 
apoplexy. On recovering consciousness he was unable to open his mouth or 
to articulate. Right side of body partially, and left side of face completely 
paralyzed. 29. — Seems better ; jaws relaxed ; swallows more easily. Dec. 
4. — Has gained some power over side, but is still unable to speak. Discharged 
by request. 

XXXIY. F. R., set. 22, fireman, admitted May 9, 1845. Five weeks ago 
patient fell from a locomotive, striking his head violently, but from this he 
apparently recovered. Ten days ago, while seated, he suddenly fell, and 
since his right side has been entirely paralyzed, and his speech rather inartic- 
ulate ; no amesthesia ; the sight of right eye is impaired, and its pupil does 
not contract well ; the tongue goes to the right, and the right side of face is 
red and hot, as is also the conjunctiva of same side ; this phenomenon is ex- 
actly limited by median line. Nov. 17. — Has had electricity and tonics ; is 
much better ; can speak more distinctly. Discharged, improper object. 

XXXY. Mary C, set. 47, widow, admitted Oct. 26, 1844. Six days ago she 
went to bed feeling as usual. On awaking found right side drawn up and 
paralyzed ; in course of day lost all power of motion, and vision became dim; 
no coma. On admission there appears to be a little anaesthesia on right side ; 
tongue goes to right ; speech affected. Nov. 6. — Last night had a slight 
convulsion ; was leeched and cupped with relief. Nov. 22. — Patient is dis- 
charged, cured. 

XXXYI. A. W., set. 20, male, admitted Dec. 20, 1844. Patient remained 
in the ward until Dec. 26 in a semi-comatose state ; without palsy, except 
that tongue pointed to right side, and that when spoken to lie only answered 
"no ; " on this day he walked about and went to bed in afternoon better ; 
was found on 27th, in morning, with complete paralysis of right ride. 30. — 
Lies quietly ; is a little more lively, but still says ' ' no " to everything. Jan. 
23, 1845, is not better. Discharged, improper object. 

XXXYII. W. F., set, 40, seaman, admitted March 7, 1845. A few days 



THE APHASIA QUESTION. 51 

ago, being in apparently good health, lie suddenly had a convulsion, followed 
by two others, and by complete paralysis of right side with inability to speak ; 
on admission, cannot speak at all ; moves leg a little, but arm is motionless 
and ana?sthetic ; ordered blisters to back of neck and electricity. May 5. — 
Has taken strychnine with no benefit ; now walks about, but can't speak. 
June 26. — Uses a very few words ; otherwise no change. Discharged by 
request. 

XXXYIII. G. B., set. 45, admitted July 14th, 1843. Patient has been 
suffering from rheumatism for some weeks. About ten days ago he suddenly 
fell down in an apoplectic seizure ; lias not uttered a word since. His right side 
is entirely paralyzed. July 22. — Has been getting feebler. Died ; no autopsy 
allowed. 

XXXIX. N. G., set. 39, seaman, admitted April 12th, 1842. Patient has 
been ill over one year. At that time had an apoplectic stroke, followed by 
right hemiplegia and loss of speech, from which he has gradually recovered. 
Is received for obscure disease -(cellulitis) of right lower extremity. Had 
violent hiccough and gradual failure. April 13th.— Died. Autopsy, nine 
hours after death, showed cerebral substance firm and natural. In left corpus 
striatum, a cavity the size of a large pea, containing fluid ; none in ventricles. 
Leg was enormously swollen, dark and covered with gangrenous bulla?. Ko 
obstruction found in arteries or veins ; cellular tissue and muscles easily torn ; 
no heart or kidney lesions. 

XL. J. Y., act. 28, tailor, admitted May 18th, 1843. Six weeks ago had 
epistaxis, which lasted three weeks, (!) and upon this ceasing while in bed, 
he had an apoplectic stroke, losing motion and sensation in right half of 
body; speech completely lost; within two days has spoken a little. June 1. 
— Is not much improved. Discharged ; improper object. 

XLI. Mary M., a;t. 49, married, admitted January 14th, 1843. Had apo- 
plexy on January 12th. On admission, has paralysis without anaesthesia, on 
right side ; mouth is drawn to left. Seems to comprehend questions, but 
speaks in a hesitating manner. Discharged February loth, by request. 

XLII. Oliver R., set. 3C, seaman, admitted December 25, 1818, for hemi- 
plegia. A short time before he was suddenly seized with a pain in left side 
of head, and fell down in a fit. He recovered from this but gradually, hav- 
ing lost the use of the muscles of the right side of face (body meant) ; mouth 
and tongue are drawn to left side ; right eye has photophobia ; articulation 
is much disturbed. Has equal command over upper and lower extremities. 
Was purged actively. On 19th of December, while at dinner, he suddenly 
had vomiting ; sweated profusely in evening and complained of cold. At 
night he became comatose. December 20. — Has been bled without effect ; 
died. Autopsy : great serous effusion under arachnoid. About middle of 
the anterior lobe of left hemisphere an abscess was found, which extended 
externally to the dura mater, and appeared internally connected with the 
lateral ventricle. It was about four inches in circumference, and contained a 
dirty colored fluid. The surrounding brain substance was much diseased and 
broken down. A portion of the cerebellum was indurated, the dura mater 
covering it appearing to have been inflamed. Thoracic and abdominal vis- 
cera normal. 



52 TEE APHASIA QUESTION. 

XLIII. A.F., set. 48, painter, admitted September 15th, 1818. One week ago 
was suddenly affected with loss of sensation and motion in right side of body: 
' ' a great impediment in his speech soon followed." On admission is as above ; 
left pupil dilated. September 28th. — Discharged relieved. This patient was 
seen later, when he had completely recovered. 

CASES EST WHICH APHASIA OCCURRED WITH LEFT 
HEMIPLEGIA. 

XLIV. J. J., set. 40, seaman, admitted June 9, 1850. Has been working 
in fire-room of steamship at night ; on 5th inst., after having headache several 
days, he went in evening to water-closet, and, while there, had a severe pain 
in shoulder, and pricking sensation over entire right side ; fouud that he had 
lost power over left. On admission has complete paralysis, and slight anaes- 
thesia of leftside of body, "utterance is imperfect." October 15th. — Has 
had tonics and electricity ; is discharged cured. 

XLY. J. B. M., set, 38, book-keeper, admitted Sept. 25, 1855. On 22d., 
while going to dinner, he suddenly fell ; he did not lcse consciousness, and 
had no convulsions. On trying to rise, he found his left side paralyzed, and 
was unable to call for assistance ; next morning was found and taken care of. 
On admission, the left side is totally palsied, but not ansesthetic ; face turned 
somewhat to one side ; "has some slowness and difficulty of speech." He 
seems to have enjoyed good health previously, and had been regular inhabits; 
may have had occasional headache. October 18th. — Is discharged, relieved. 

XLYI. J. S., set. 35, soldier of 61st Regiment, N. Y. volunteers, admitted 
September 20, 1861. Patient was transferred from State Hospital; has been 
hemiplegic on left side, and has lost speech ; is now able to walk about and 
help himself. No treatment excepting good food. January 20, 1863. — Patient 
is transferred to United States Army General Hospital in this city. 

CASES IN WHICH APHASIA OCCURRED WITH DOUBLE 
HEMIPLEGIA. 

XLYII. J. B., set. 62, porter, admitted December 6, 1860. Brought in 
semi-comatose, with left pupil dilated and fixed ; face flushed ; pulse irreg- 
ular; body relaxed. December 9. — Patient is rather more conscious; tries to 
protrude tongue when asked; left side of body is completely paralyzed, right 
partially so. Ordered wet cups to temple and pot. iod., .60 t.i.d. 12th 
— Patient now moves right side pretty freely and left slightly. He under- 
stands all that is said to him, but cannot speak. Takes beef-tea and pot, 
iodid. January 7. — After last note patient got bad bed-sores, and last week 
was attacked with facial erysipelas ; in spite of sujyporting treatment, he died 
to-day. No autopsy. 

XLYIII. R., set. 41, seaman, admitted September 2d, 1841. About one 
month ago, while lying in berth, he suddenly became paralyzed on both sides 
at the same moment. Since, he thinks that he has gained some power over 
legs. September 14. — Has been taking iod. potass. Last night he was at- 
tacked with spasmodic twitching of all his limbn and right side of face. 



THE APHASIA QUESTION. 53 

Cannot swallow as well as before, and his speech has entirely failed. He ap- 
pears to understand, and attempts to speak. Tongue is protruded; sphincters 
paralyzed. Cont. iod. potass. September 27. — Has had a good deal of rigid- 
ity of limbs; and has gradually failed; died. Autopsy, eight hours post 
mortem, head only examined. The superficial vessels are congested; some 
G5. cc. of limpid fluid in cells of pia mater. The arachnoid at base was 
cloudy and tough. When transverse sections of the brain were made, it was 
found to be of a natural consistency. The medullary portion was covered 
with numerous points of blood ; nothing peculiar was discovered in hemi- 
spheres. The ventricles contained about 15. cc. of serous fluid. The 
right corpus striatum was found diseased. Its cineritious portion for the 
space of a hickory nut (2. centimeters in diameter), was transformed into a 
soft, reddish vascular pulp. The left was healthy, as w T ere theoptic thalami. 
The rest of the brain was healthy.* 

CASES IN WHICH APHASIA OCCURRED WITHOUT 
HEMIPLEGIA. 

XLIX. T. R., oBt. 35, seaman, admitted June 14, I860. Patient has al- 
ways been healthy ; somewhat intemperate; never had syphilis. This after- 
noon, while working, he fell down unconscious. On admission, is insensible ; 
had no convulsions; pulse 90; no paralysis; heart healthy. June 15. — Has 
slowly returned to consciousness. There is a complete loss of speech; "mus- 
cles of his tongue and of speech are entirely paralyzed, so that he cannot pro- 
trude his tongue nor utter a syllable. His intellect appears to be slow, though 
he evidently comprehends everything." Answers by signs of head. Is able to 
walk about; eats and sleeps well. June 30. — Continues to improve; is slowly 
regaining speech, but cannot protrude tongue. July 13. — Patient now pro- 
trudes tongue well, and speech is slightly less difficult. Discharged relieved. 
(If the patient spoke at all, his mutism must have been owiug to something be- 
sides tongue paralysis.) 

L. K., set. 21, seaman, admitted November 14, 1866. Patient gave an un- 
certain history of intermittent fever, contracted a month or so before in one 
of the Gulf ports. On admission, he spoke in a peculiar manner. The first 

* These cases are open to the objection that they might have been instances of 
complete paralysis of the tongue. But in case XLVII., no difficulty in swallowing 
is mentioned; and in case XL VIII., it is positively stated that the tongue was pro- 
truded. Dr. Jackson's opinion on the bearing of such an objection to cases of 
aphasia is worth reproducing. '•' I may say, too, that I have never seen paralysis 
of the tongue (i.e. decided paralysis. ...'), even on one side, with pure hemi- 
plegia. There is, generally, weakness, affecting all the four limbs, although the 
limbs on one side may be weaker than on the other. I state this as a mere matter 
of fact, but it is easy to explain it by anatomy. The nuclei of the ninth nerves are 
imbedded very near the decussation of the fibres from the limb, so that an in jury in- 
volving the nucleus even of one side, would be, from continuity, likely to damage 
the motor fibres of both sides of the body — those on one side before, and those on 
the other after they had crossed." And he adds in another place, that dumbness 
(paralysis of the tongue) would always be accompanied by difficulty in deglutition 
or by the impossibility of the act. 



54 THE APHASIA QUESTION. 

words of any sentence came forth easily and naturally, but the last, often in- 
cluding the important verb or noun, were either gotten out with difficulty, or 
not at all. The articulation was perfect, but there was a notable failure of 
memory of which he seemed aware. He had no headache, and no sign of 
paralysis. He presented the appearance, so commonly seen- in patients com- 
ing from the South, designated as malarial cachexia. November 15. — Patient 
seems to have fallen into a curious lethargic state. The speech is almost en- 
tirely lost ; but there is neither delirium nor coma ; he is intelligent, under- 
standing and answering gestures; he makes use of a few words, but never to 
the point ; he seems to wish to be let alone ; urine and fasces passed sponta- 
neously, and are normal; the symptoms do not resemble those of congestive 
malarial fever ; the eyes are not remarkably brilliant, and he does not seem 
to have headache; the pulse ranges about 100; nothing abnormal heard in 
heart or lungs; is taking .75 of quinise sulphas under the skin, daily, in 
three doses; whiskey 16. cc. and beef-tea. 19. — In the last few days 
there has been no marked change in his condition; he often makes use of the 
phrase "what is it?" sometimes says "yes " without reason; still seems ra- 
tional; puts out his tongue b} r imitation and quickly too ; has been restless, 
but at no time delirious ; two or three times a day he makes use of a few other 
words ; once yesterday saying five in answer to a question, but not forming 
any sentence ; he seems to have rather more fever, with but small morning re- 
missions; bowels being constipated, are to-day moved by injection; when he 
has a call of nature he demands the nurse's help 'with the phrase " what is 
it? 1 ' Cont. quiniae and food; seems to be failing in spite of this; tongue 
coated, but never dry. 23. — Fever seems to have assumed a more continued 
type ; no change in cerebral symptoms ; no paralysis ; no delirium ; speech 
same; has had infusion of serpentaria instead of quinia lately. 24. — Rather • 
suddenly, at 4 o'clock a.m., died. 

The autopsy, nine hours after death, was made with great care. On re- 
moving the calvarium, the dura mater was found much congested, the arach- 
noid remarkably dry, and the vessels on the convexity of the brain greatly 
distended with blood ; not a trace of lymph was here found. On examining 
the base of the brain, however, a large patch of false membrane was found 
extending from the optic commissure backwards over the crura cerebri, the 
pons Varolii and the medulla oblongata, terminating in a thin film on the in- 
ferior surface of the cerebellum. The membrane was thickest over the.pons, 
being there 2.5 millimeters through and very firm. None of the nerves 
appeared altered, nor was there any change in the brain substance beneath 
the membrane. Anterior lobes (particularly the left with the third convolu- 
tion and island of Reil) were examined with minute care for evidences of soft- 
ening, inflammation, hemorrhage or plugging of vessels, but nothing could be 
found. Horizontal section showed considerable punctate injection. The lat- 
eral ventricles were about half filled with a clear, straw-colored serum. The 
whole encephalon was then finely sliced, but no farther lesions were discov- 
ered. Lungs, spleen, liver and kidneys were congested. Heart was examined, 
but condition is not stated in notes. 

The results in these fifty cases were as follows : died, 14 (9 
autopsies) ; cured 11 ; relieved 13 ; not relieved, 12 ; total 50. 



CASE OF TRICHINOSIS. 55 

■ 

CASE OF TRICHINOSIS.* 

J. B., a grocer's clerk, aged nineteen years, was admitted into the New 
York Hospital, service of Dr. Thomas F. Cock, June 19, 1867, suffering from 
anasarca. The patient stated that he had been ill three weeks, and that dur- 
ing the first ten days he had suffered from violent vomiting and diarrhoea, 
followed by great debility and by dropsy. On admission he appeared ex- 
tremely anaemic ; the oedema was so remarkably elastic that pitting could 
only be produced upon the legs ; the tongue was clean, smooth, devoid of 
epithelium, and in its anterior part disposed to dryness ; the stomach was 
irritable, he said, but he managed to retain at least one meal a day ; during 
the past few days constipation had succeeded to the previously relaxed state 
of the bowels ; the pulse was weak, small, and beating about 112 times a 
minute ; respiration was normal, and there was no increase of bodily temper- 
ature. The urine was at once examined, and found to be of a pale color, of 
normal specific gravity, and perfectly free from albumen. The patient was 
ordered 120. cc. of sherry wine, milk diet, and a small dose of the ammo- 
nio-citrate of iron in tincture of cinchona. My suspicions that the case was 
one of trichinosis were strengthened by the negative results of the urin- 
ary examination. Direct questioning elicited the fact that considerable 
muscular pain and soreness had been experienced during the second and third 
weeks of illness ; and that previously to the attack he had been in the habit 
of gating half-cooked ham in sandwiches, and also of occasionally cutting off 
small pieces of raw ham in the grocery and eating them. 

On the 28th the patient had gained a little strength, vomiting having occurred 
a few times. Eggs and milk had been eaten, and 180. of wine drunk 
daily. The tartrate of potassa and iron had been substituted for the citrate, 
as a chalybeate less likely to disturb the stomach. Repeated examinations of 
the urine had been made with uniformly negative results. On stating to Dr. 
Cock my reasons for venturing a diagnosis of trichinosis, he very kindly gave 
permission to resort to the proving examination. The patient readily and 
intelligently gave his consent. Localized anaesthesia was produced by means 
of ether and Richardson's apparatus, and a small portion of the deltoid mus- 
cle was removed. On tearing apart the muscular fibres in diluted glycerine 
and looking at the preparation with a low objective, ten or twelve living 
trichina} were seen. The cysts w r ere very distinct, located in the muscular 
substance, their perfectly limited rounded ends beginning to become cpaque 
from granular deposit. About their extremities were masses of fat globes and 
cells. 

The trichinae which were still inclosed in cysts presented a constant ver- 
micular motion; while those which were free in the liquid of the preparation 
were so active as at times to leave the field (a narrow one at one jump. 
These movements were retained by the trichinae, thus prepared, for four days. 

It was Dr. Cock's opinion, that as all symptoms of intestinal irritation had 

* From the New Yorlc Medical Journal, May, 1868. This was probably the 
first case of trichinosis in America where the diagnosis was confirmed during life 
by the microscope. The case occurred while Dr. Seguin was House Physician of 
the Hospital. -R. W. A. 



56 ACUTE OCULAB (EDEMA. 

ceased, and as it might be presumed that the parasites had all reached a mus- 
cular lodgment, there were no indications in the case, excepting to feed the 
patient carefully and to give him iron cautiously. This plan was carried out, 
and slow improvement was observed daily in color and strength ; the swelling 
disappearing rapidly from all parts excepting the legs. August 13. — The 
patient, although still pale, is discharged cured. 

It is to be regretted that the duties of the hospital were so pressing upon 
the resident staff as to prevent the proper inquiries and examinations so essen- 
tial to the completeness of such a case. 



A CASE OF ACUTE OCULAR (EDEMA— CAUSE UNKNOWN * 

B., a private in Co. B, 3d U. S. Cavalry, aged 18 years, a native of Penn- 
sylvania. Has never enjoyed good health. From the age of 15 to date of 
enlistment, last March, he worked in an iron mill, and was exposed to great 
heat and vivid light. A few years ago he had intermittent fever. Has always 
had a tendency to diarrhoea, and is now under treatment for an attack that 
threatens to become chronic. He is pale, flabby, looks old, face and forehead 
wrinkled. When a child he suffered from night blindness. Sept. 24th, he 
presented himself with his left eye much swollen; says that ten minutes before 
his eye was well. He was reading, when suddenly a severe smarting pain was 
felt in the inner canthus, and was at once followed by swelling. He is cer- 
tain that no foreign body entered the eye. The lids are externally cedematous" 
and nearly closed. On opening them, an almost complete chemosis is seen, 
the ring being imperfect at its upper outer part. There is no injection of blood- 
vessels and no lachrymation ; pupil normal. I applied a solution of nitrate of 
silver ( 3. to 30. aq.) freely over the chemosis, and directed a light wet com- 
press to be applied during the evening and night. The next day the eye was 
about normal. 

Second attack, Oct. 3d, at 1 p.m. I had occasion to see a wounded man in 
my hospital, and asked several questions of B., who was watching him. His 
eyes were then in a normal state. Hardly had I returned to my room — cer- 
tainly not more than five minutes — than B. came to me hurriedly with his 
right eye swollen. He had experienced the smarting, and the appearance of 
the eye was precisely similar to that of the left eye ten days previously. There 
was no sign of inflammation. At 2 p.m. a complete and heavy ring of swelling 
surrounded and nearly buried the cornea. I pursued the same plan of treat- 
ment as before, and in twenty-four hours all was well. 

Patient states that he had the first attack of this curious affection in 1860, 
while at work in a field. Since, he has had from two to six attacks each 
year. This year he was affected once in April and once in July, besides 
the two attacks detailed above. He feels certain that in all instances the 
symptoms and appearances have been the same ; and often the disease sub- 
sided spontaneously. Once, in 1860, both eyes were affected at one time. 

His mother and sister "have always had weak eyes," and have suffered 

* From the N. Y. Medical Record, Jan. 1, 1869. 



HE111PLEGIE SPIN ALE. 57 

from repeated similar attacks of oedema of the eyes. His father has excellent 
sight, though he has worked for many years in the iron mill. 

The irides are pale gray ; pupils habitually a trifle dilated ; urine contains 
no albumen ; heart healthy. Patient suffers much from epistaxis, in sum- 
mer mostly. 

There are three main points of interest in this case. First, the extremely 
sudden formation of the oedema and absence of the usual symptoms attending 
inflammatory processes. 

Second, the apparent hereditary character. 

Third, the coincidence of the disease with a semi-cachectic state. 



CAS DE LESION PROBABLE DE LA MOTTLE LATER ALE DROITE 
DE LA MOELLE EPINLERE, DANS LA REGION CERYICALE IN- 
FERIEURE. AYANT PRODUIT DE L'ANESTHESIE D'UN COTE 
ET DE LA PARALYSIE DE L'AUTRE.* 

Le sujet de cette observation, le capitaine R., du S e regiment de cavalerie, 
dans i'armee des Etats-LTnis, age de 36 ans, naturellement tres-fortement con- 
stitue, a toujours joui d'une sante exceptionnellement bonne. Etant en gar- 
nison a Natchez, dans l'Etat du Mississipi, pendant i'automne de 1863, il lui 
arriva un accident qu'il decrit en ces termes : II etait dans Thabitude chaque 
jour de se promener a cheval. Le 21 octobre, prenant cet exercice, il apercut 
une rue dans laquelle il n'etait jamais entre, et s'y lanca au grand galop. A 
peine y fut-il entre qu'il vit que c'etait une impasse. M. R. ne put arreter 
son cheval, et tous deux furent precipites dans un fosse ayant des murs de 
briques et d'environ 15 pieds de largeur et 12 de profondeur. Ce fosse termi- 
nait Timpasse, et de l'autre cote se trouvait une maison. 

3Ialgre la force terrible du choc, le cheval ne flit nullement blesse, mais 
Bf. R. fut releve insensible et porte a l'hopital militaire. 

Environ une heure apres Taccident, il revint a lui et constata sa condition. 
II n'avait qu'une seule blessure. une laceration du cuir chevelu sur le parietal 
gauche, mais son corps etait si completement paralyse a droite qu"il ne pouvait 
meme remuer un seul doigt. Dans ce meme cote la sensibilite etait conservee, 
et il pense meme que les sensations tactiles etaient plus distinctes qu'a l'etat 
normal. Dans le cote gauche du corps il y avait anesthesie incomplete, avec 
conservation du mouvement volontaire. La perte de sensibilite etait totale 
dans les parties animees par le nerf cubital. La tete etait fortement inclinee 
vers Fepaule droite. II est certain qu'il n'y avait point de paralysie a la face, 
et que ses sens etaient normaux. Pas de paralysie des sphincters ni d'anaphro- 
disic. Le peu de dyspnee qu'il ressentit les premiers jours se dissipait lorsque 
ses epaules etaient soulevees. II ne perdit plus connaissance et n'eut pas de 
delire. 

Le troisieme jour, le mouvement volontaire lui revint un peu dans le cote 
droit, et apres cela il s'ameliora progressivement. Yers la fin de la deuxieme 
semaine il quitta son lit, avec l'aide du garde-malade, et fit quelques j)as dans 

* Extrait de 1' Archives de Physiologic normalc et pathologique, mai-s,18T0. 



58 HEMIPLEGIE SPINALE. 

la salle en s'appuyant sur le dos crune chaise ou sur le bras du garde-malade. 
Une semaine plus tard il se promeuait lentenient, faisant peu de pas a la fois, 
tout seul. A cette epoque (troisieme semaiue), il s'apercut pour la premiere 
fois que la sensibilite des doigts de la main gauche s'ameliorait, mais il ne 
remarqua pas l'etat de la jambe. En sortant du lit, il fit l'observation que le 
cote droit du corps se refroidissait plus facilement que le gauche, parti cularite 
qui persiste encore aujourd'hui. Six niois apres l'accident, il se rendit & son 
regiment, et avec de l'assistance en montant, put allcr a cheval. A cette epo- 
que, le cou s'etait completement redress^, et depuis lorsil a continue a gagner 
lentenient en force et en agilite du cote droit. 

Au moment ou cette observation est redigee (juin, 1869), M. R. est en par- 
faite sante et soutient tres-bien les fatigues de la guerre. A pied il a Pair tin 
peu gene, mais cela tient a un dcgre tres-minime d'atrophie du cote droit du 
corps. Une fois a cheval, il est completement dans son element et se montre 
admirable cavalier. Sa force physique est grand e, et il fait l'exercice du sabre 
egalement bien des deux mains ; la main droitc est un peu congestionee, et 
les doigts sont en apparence contractures, mais cela est plutot une attitude 
vicieuse qu'une retraction musculaire. Avant son accident, il ecrivait de la 
main droite ; maintenant il conserve l'habitude prise pendant les mois de para- 
lysie d'ecrire avec la gauche, mais il signe toujours avec la droite. La jambe 
et la cuisse gauche n'ont pas une sensibilite tout a fait normale, autant que je 
l'ai pu estimer avec une epingle. II pense que la main droite est encore 
hyperesthetique, et il a remarque que de ce cote les ongles poussaient plus 
rapidement quii gauche. 

L'histoire du traitement est plutot curicuse qu'importante. Les chirurgiens 
a l'hopital militaire de Natchez crurent a une lesion dans riiemisphere cerebral 
gauche. L'erreur de diagnostic s'explique en partie par la presence des deux 
faits que voici : plaie sur le parietal gauche et hemiplegie a" droite. lis deci- 
derent de laisser M. R. sans traitement, sauf qu'apres les premiers jours le 
galvanisme (courant electro-magnetique interrompu) fut applique journelle- 
ment aux membres paralyses pendant quatre mois. Dans le mois d'octobre 
1864, profitant d'un conge, il se mit entre les mains, d'un horloger de Louis- 
ville, qui lui fit des applications irritatrices produisant des pustules. II se 
servait d'un appareil compose d'une douzaine de pointes d'aiguilles, avec lequel 
il faisait penetrer une pommade dans la peau du cot6 droit, qui etait encore 
faible. Toutes les parties de ce cote du corps furent Tune apres l'autre 
couvertcs de pustules, le traitement durant plusieurs semaines. M. R. croit 
que cette medication lui fit du bien, et depuis il ne s'est plus soigne. 

Cette observation est malheureusement tres-incomplete. Elle repose presque 
entierement sur ce que le malade a lui-mSme recueilli. Je n'ai pu etudier 
d'une maniere satisfaisante l'etat des diverses especes de sensibilite dans le 
cote gauche, car les details du cas me furent communiques pendant line 
expedition contre les Indiens dans le territoire du Nouveau-Mexique, et ce 
n'est pas en pareilles circonstances qu'un medecin se trouve muni d'assthesio- 
metre, etc. 

La premiere question qui se presente en cherchant a, analyser le cas est 
quelle partie du systeme nerveux central a ete lesee. 

On peut completement rejeter l'opinion des chirurgiens qui traitfcrent 



HEMIPLEGIE SPINALE. 59 

M. B. eu premier lieu. A moins de supposer deux lesions simultanees, une 
dans Themisphere gauche et l'autre dans la moelle epiniere, les symptomes ne 
peuvent etre expliques. Mais Tabsence de paralysie faciale s'oppose a Tad- 
mission de l'existence d'une lesion cerebrale. Le malade a souffert des 
symptomes qui suivent : 

A droitc. A gauche. 

1. — Paralysie complete du mouve- 1. — Conservation du mouvement vo- 
ment volontaire dans les deux ex- lontaire. 

tremites. 

2. — Une contracture (?) de muscles 2. — Une paralysie (?) des muscles 
inclinant la tete vers l'epaule. dont Taction est d'incliner la tete 

vers l'epaule. 

3. — Une hyperesthesie dans ces 3. — Anestbesie complete dans la re- 
memes extremites (?). Certainement gion animee par le nerf cubital, in- 
conservation de sensibilite. complete ailleurs. 

4. — Congestion de la peau et deve- 
loppement des ongles plus rapide- 
ment que du cote oppose. 

On ne peut s'empecher de reconnaitre ici les signes d'une hemiplegie 
spinale ; une forme de paralysie dont on doit la caracterisation a M. Brown- 
Sequard.* 

Se basant sur une pliysiologie de la moelle epiniere qiril avait lui-meme, 
par de rcmarquables decouvertes, plus contribue que personne a etabflr, il 
parvint it expliquer les resultats, en apparence si obscurs et indechiffrables, 
de certaines lesions spinales. M. Brown-Sequard a recemment f jjublie une 
serie de lecons sur Themiplegie spinale, remplie de faits nouveaux qui ne 
laissent plus de doutes sur le sujet. 

En comparant les symptomes presentes par le capitaiue R. avec ceux des 
malades etudies par M. Brown-Sequard, il est certain qu'ils appartiennent it 
une meme categoric. La lesion dans Tobservation que je rapporte etait done 
dans la moitie lateral droite de la moelle epiniere. 

A quelle hauteur siegeait la lesion ? II est certain que les 
nerfs diaphragmatiques n'ont point ete paralyses, car le peu de 
dyspnee dont il s'est plaint se dissipait immediatement apres 
l'elevation des epaules. La sensibilite etait le plus affectee dans 
les parties ou se distribue le nerf cubital, nerf qui semble prendre 
son origine des deux cordons inferieurs du plexus brachial, cor- 
dons qui sont formes par la derniere racine cervicale et la prem- 
iere dorsale. Consequemment la moelle n'etait point lesee au 
niveau de la quatrieme paire cervicale, mais l'etat pathologique 
etait a son maximum a l'origirie de la huitieme paire. 

* Lectures on the physiology and pathology of the nervous centers : delivered 
before the Royal College of Surgeons of London in May, 1858.— Philadelphia, 1860. 
f Lancet, Nov. 7, 1868, et dans plusieurs numeros suivants. 



60 EEMIPLEOIE SP1NALE. 

Quelle etait la nature de la lesion ? 

Le resultat heureux obtenu si rapidement suffit pour faire 
rejeter la plupart des causes connues de l'hemiplegie spinale. 
En premier lieu, une fracture du rachis ne peut etre admise ; et 
de plus, j'ai constate qu'il n'existait aucune deformation de la 
colonne vertebrale. Une liemorrliagie des meninges, assez con- 
siderable pour produire une anesthesie si persistante, aurait 
necessairement ete tres-considerable, et de plus le sang aurait 
eu de la tendance a se repandre autour de la moelle, produisant 
ainsi des symptomes bien differents de ceux observes dans l'ob- 
servation. Une dechirure complete de la moitie laterale droite 
de la moelle n'est guere plus compatible avec les symptomes et 
avec le re tour du mouvement volontaire pendant la premiere 
semaine. En outre, comme M. Brown-Sequard l'a fait remarquer, 
l'anesthesie est permanente lorsqu'il exist pareille lesion. Dans 
un cas qu'il a pu observer plus de vingt arts apres la division 
d'une moitie laterale de la moelle dans la region cervicale supe- 
rieure, il a constate un retour assez complet du mouvement vo- 
lontaire dans les membres du cote de la lesion, mais a peine y 
avait-il trace de sensibilite dans le cote oppose. La conduction 
motrice s'etait retablie, la conduction sensitive etait interrompue 
d'une maniere permanente. II me semble qu'une lesion tres- 
limitee dans la substance grise de la moelle, au niveau de la 
huitieme paire cervicale, lesion consistant en une dissociation de 
certaines cellules d'avec leurs fibres nerve uses, avec rupture de 
vaisseaux capillaires et hemorrhagic extremement minime, expli- 
querait parfaitement les symptomes. Mais, en outre, il faut faire 
la part d'une alteration de nutrition dans d'autres parties de la 
moelle, alteration consequente au traumatisms La paralysie, 
qui a disparu completement en quelques mois, ne pouvait de- 
pendre entirement d'une interruption des conducteurs moteurs ; 
il a du y avoir aussi une alteration de nutrition par action 
reflexe. La sensibilite est revenue en presque totalite, aussi 
avec une grande rapidite; et d' apres les preuves fournies par 
M. Brown-Sequard de l'incurabilite de l'anesthesie a la suite de 
lesions de la substance grise de la moelle, on doit conclure que 
l'anesthesie chez M. R. dependait presque entirerement de 1' alte- 
ration de nutrition dans la moitie droite de la moelle. Mais 
il y a certainement eu traumatisme, ainsi que l'atteste la per- 
sistance d'un degre appreciable (peut-etre plus grand qu'il ne 
m'a paru) d'anesthesie. L'etat congestionne de la main droite, 



HEMIPLEGIE SPINALE. 61 

ainsi que la production anormale des ongles, indiquent une 
alteration permanente dans la substance grise. 

Comment expliquer la position de la tete pendant plusieurs 
mois ? Deux hypotheses s'offrent ; une de supposer une paralysie 
des muscles du cou, du cote gauche ; l'autre, de considerer la 
deviation comme due a un spasme des muscles a droite. La 
premiere hypothese ne peut etre soutenue, il me semble, parce 
qu'une paralysie des muscles lateraux du cou aurait presque 
certainement entraine une diminution dans le mouvement de 
l'epaule et du bras du cote correspondant ; et M. K. dit pos- 
itivement qu'une heure apres l'accident il avait l'usage complet 
du bras gauche. La contracture des muscles a droite pour- 
rait s'expliquer par l'alteration de nutrition dans la moelle au- 
dessus de la lesion. On ne pourrait la considerer comme un 
epiphenomene, du a la violence du choc. II me semble que la 
premiere opinion est plus en accord avec les connaissances que, 
grace aux travaux de M. Brown-Sequard principalement, nous 
avons de la production de phenomenes multiples et varies par 
une seule cause d'irritation. 



AUTOPSY OF A CASE OF MANIA.* 

Mania; granular degeneration of ventricles ; cortical sclerosis of cord. — S. S., 
set. 43, married. Can., stonecutter, admitted July 10, 1870. First symptoms 
noticed two months ago. Had a slight fit, which was followed by symptoms 
of subacute mania. He steadily grew worse and became unmanageable at 
home, on account of violence towards family and others. At times has been 
rational, but most of the time incoherent, having delusions in regard to being 
a policeman, owning livery stables, etc. Previously to his having this "fit'' 
he was thought eccentric. 

August 9. — Has had no active symptoms until to-day, when he became delir- 
ious and required restraining in bed. 

Sept. 1. — Is up and about ward as usual, though he seems more stupid and 
irritable. 

20th. — Transferred to the " Excited Ward " on account of a growing dis- 
position to molest other patients. Imagines that they call him bad names, etc. 
Patient is somewhat deaf. 

Oct. 10. — General health failing. Is taking tonics and stimulants. Soils 
clothing and bed. 

JVov. 1. — Did not seem to recognize his wife, who visited him two or three 
days ago. Frequently sutlers from colic. 

11th. — At six o'clock a.m., was discovered in a " fit " by the attendant. 
The "fit" seems to be apoplectic. Has stertorous breathing; flushed counte- 
nance; pulse 132, and very strong, carotid arteries beating violently ; pupils 
contracted and not responsive to light. No reflex movements of limbs pro- 
duced by tickling feet. "When first seen by attendant arms were jerking. No 
evident paralysis of any of the limbs. At 6 o'clock p.m., no material change. 
Has occasional spasmodic movements of arms, and spells of jerking, and 
irregular breathing. Sweats profusely, and rmsses large quantities of urine. 

12t7i. a.m. — Pulse not as strong. The paroxysms of irregular respiration 
continued through the night. No other change. Noon. — Breathing more 
regular ; pulse better ; pupils respond to light ; he makes attempts to swallow. 
Ordered Some stimulants. Is sensible to pain of pricking and pinching. 
Right side apparently more sensitive than left. Temperature normal. G o'clock 
p.m. — Swallows whiskey and water, though with difficulty. Pulse 100. . 

13th. — Apparently better. Takes milk-punch aud beef-tea with less diffi- 
culty in swallowing. Respiration more regular. 5 p.m. — Is about as in a.m. 
7 p.m. — Reported in a dying condition. Death took place at 9 p.m. 

Autopsy. — Body examined twelve hours after death ; weather cool. Rigor 

•- By A. M. Shew, M.D., and E. C. Seguin, M.D. Extract from the American 
Journal of the Medical Sciences for July, 1871. 



AUTOPSY OF A CASE OF MANIA. 63 

• 
mortis moderate and universal. Some hypostatic congestion of skin of back 
and limbs. Small bed-sore formed over sacrum. 

Spine and contents. — Fat next to dura mater injected. But little fluid under 
arachnoid. Dura mater and arachnoid appear perfectly healthy: there being a 
few filamentary adhesions between the two in region of cervical enlargement, 
posteriorly. On the anterior surface of spinal canal there is found a small 
tumor, the size of a large pea, situated in the substance of the posterior com- 
mon ligament, opposite the fibro-cartilage lying between the last dorsal and 
first lumbar vertebra?. It pushes the dura mater somewhat forward, but not 
enough to have produced any pressure on cord. The tumor is fibro-cartilag- 
inous. On making sections through different parts of the cord, no abnormal 
appearance is discernible to the naked eye, except a very unusual develop- 
ment of vessels in the gray matter and near the anterior fissure. Spinal cord 
is placed in Midler's fluid for transportation. 

Skull and contents. — Bones and dura mater normal. Pacchionian bodies un- 
usually numerous. The arachnoid is not perfectly transparent along vessels, 
but the milkiness is hardly pathological. A minute inspection of the entire 
external surface of the cerebrum fails to reveal any lesions. The pia mater 
everywhere peels off well. On section, the gray matter of the convolutions 
appears unusually dark. The centrum ovale majus is much injected. Opto- 
striate bodies normal. 

The ventricles are the seat of a very interesting lesion. In the first place, 
they are all considerably dilated, and contain a good deal of clear fluid. 

Secondly. — The floor of the lateral ventricles, half way up the lateral bound- 
ary, appears granular and thickened. The granulations, easily felt and seen, 
are translucent, pearl-like, and vary much in size, from a mere point to the 
bulk of the head of a small pin. On passing the fingers over the diseased 
tissue it appears unusually firm. . The third ventricle and infundibulum are 
considerably enlarged, and studded with granulations ; the same being true 
of the aqueduct of Silvius. The foramina of Monro measured over one-half 
a centimeter in diameter, and the lesion involves them, as well as the 
septum lucidum. The roof. of the ventricles is normal; and so are the choroid 
plexuses. 

Cerebellum appears perfectly normal: but the valve of Yieussens is the seat 
of the granular degeneration above described. Medulla oblongata appears 
healthy to naked eye, except that floor of fourth ventricle to the apex of the 
calamus scriptorius exhibits the granular degeneration, though to a less 
degree than the lateral and third ventricle. Nerves at base of brain appear 
normal. 

Thorax and contents. — Heart normal, contracted; commencing atheroma of 
arch of aorta. 

The lungs do not fully collapse on exposure. Left lung presents some 
recent adhesions of its lower part with costal pleura; no fluid. The lower 
lobe is hepatized and presents a number of patches of commencing resolu- 
tion; pieces sink in water. Lower part of upper lobe slightly congested; at 
apex there is a wrinkled cicatrix the size of an almond, underneath which lies a 
cretaceous mass as large as a pea, with tubercular (?) granulations, somewhat 
smaller, imbedded in the lung tissue around it, in a zone one inch in diameter. 



64 AUTOPSY OF A CASE OF MANIA. 

Right lung exhibits only extreme congestion and oedema of upper and lower 
lobes; the middle lobe being normal. No trace of tubercles in this lung. 

Abdomen and contents. — The stomach is the seat of Considerable ecchymosis 
along the lesser curvature, and there are traces of this in the large cul-de-sac. 
Kidneys of usual size; capsules peeling off normally. Cortical portion of 
right kidney is, perhaps, a little pale. 

Liver, spleen, and intestines healthy. Some urine in bladder ; is not albu- 
minous. 

Microscopical examination. Spinal cord. — After hardening in a dilute solu- 
tion of chromic acid, sections were cut horizontally from different regions of 
the spinal cord, and prepared by Clarke's method. That is to say, the cuts 
were stained by a neutral solution of carmine, soaked in alcohol, transferred 
to absolute alcohol, floated on oil of turpentine to give transparency, then 
mounted in Canada balsam dissolved in chloroform. The following is the 
result of the study of these sections in order, beginning above, with a power 
of one hundred diameters. 

Section No. 1, made in the decussation of the pyramids. Circumferential 
layer of reticulum is perhaps a trifle heavier than usual, as are some of the 
trabecule running inward from it. The central canal is very small, but not 
altered; and no lesion is evident in the white or gray substances. 

Section No. 2, made 3 c. below decussation. The increased thickness of the 
circumferential part of reticulum has become very decided, and constitutes a 
cortical sclerosis. The framework is denser, and secondarily the nerve fibres 
near the edge of the section are atrophied in large numbers ; many bearing 
but a very small quantity of myeline around the axis cylinder, many others 
being apparently reduced to the latter element; the growth of the new fibril- 
lar tissue having, as it were, strangulated them. The anterior fissure is widely 
open, the vessels running into it are abnormally large, and at its bottom, near 
the anterior commissure, there is a moderate amount of homogeneous effusion 
in the folds of the pia mater outside the vessels. On the left side, the ante- 
rior commissure is invaded, and somewhat broken down, by a dilated vessel 
with effusion of the same homogeneous material outside of it, in a manner 
precisely similar, though less in extent, to what exists in Section 4. The cen- 
tral canal is normal, but its cavity contains a quantity of the homogeneous 
effusion. 

Section JSfo. 3, made through the upper part of the cervical enlargement. 
The cortical sclerosis has diminished, but is still very evident and uniform. 
Near the bottom of the anterior fissure lies a dilated blood-vessel, and still 
deeper a quantity of homogeneous effusion, destroying, in great part, the left 
anterior commissure. There is also a want of symmetry between the anterior 
horns, the right being shorter, and looking a trifle more inward, than the left. 
The central canal is small, but normal. 

Section No. 4, made through the middle of the cervical enlargement. The 
cortical sclerosis has again increased, and is greatest in posterior and lateral 
portions of the section. At the external end of the anterior fissure, there has 
been much increase of the connective tissue of the pia mater. With a higher 
power (300 diameters), this structure may be seen sprinkled with numerous 
nuclei, evidences of inflammatory irritation. This multiplication is especially 



AUTOPSY OF A CASE OF MANIA. 65 

marked round about the vessels of the anterior fissure, and in their adven- 
titious coat. A narrow strip of pia mater extends from this part to the inner 
end, or bottom, of the anterior fissure, where it again expands, rich in nuclear 
elements, and bearing abnormally large blood-vessels, whose walls are de- 
cidedly thickened, and whose cavities are crammed with red blood corpuscles. 
In the middle, resting against the anterior commissure, in the midst of the 
connective tissue, is a mass of effused material, appearing homogeneous under 
a power of 100 diameters. From the pia mater, at the bottom of the fissure, 
there extends a new formation of fibrillar tissue filled with nuclei, inclosing 
blood-vessels, which has quite destroyed the left branch of the anterior com- 
missure; the pathological product extending into the gray matter and pos- 
terior commissure. At the place of contact of the fibrillar tissue and the gray 
commissure, is another mass of homogeneous effusion. There is more or less 
condensation of tissue round about the central canal, the cavity of which con- 
tains a homogeneous material of same aspect as that found elsewhere. The 
invasion of the left anterior commissure by the diseased pia mater has pro- 
duced a striking deformity in the wdiite and gray matters of that side. The 
left anterior column is shortened, and rounded off below ; the inner boundary 
line of the anterior horn is apparently shortened, and is thrown inward, so as 
to ajDpear quite parallel with the anterior fissure. About one-fourth of the 
so-called posterior fissure is dilated, and the resulting space contains a thick- 
ened process of the pia mater, probably itself conveying an enlarged blood- 
vessel. 

Section No. 5, made through the middle of the dorsal region. The cortical 
sclerosis continues marked, though less than in No. 4. At the bottom of the 
anterior fissure is some homogeneous effusion, but the commissure is intact. 
There is seen, back and to the left of the central canal, in the posterior com- 
missure, an opaque red spot, contrasting sharply with the adjacent*tissue, of 
an oval shape, measuring .21 by .13 mm., evidently a spot of sclerosis. The 
central canal is here very large, .5 mm. by .15 mm., irregularly quadrangular 
in outline, and is filled with homogeneous effusion. 

Section No. 6, made through the middle of the lumbar enlargement. Cor- 
tical sclerosis moderate ; exaggerated near points of exit of posterior roots. 
The anterior fissure and contained parts are very nearly normal; anterior com- 
missure intact. The central canal appears as a slit running antero-posteriorly, 
one of its sides formed by tolerably distinct epithelium, the other broken 
down ; and the lumen contains debris of epithelial elements. No trace of effu- 
sion outside of vessels. 

Section No. 7, made at a point about 2 c. above end of cord. Shows very 
great cortical sclerosis, which is, however, quite uniform. Anterior fissure 
not much involved; it contains no effused matter. The central canal is 
represented by an ovoid mass of epithelial debris. The external layer of the 
reticulum, and the trabecular running inward from it, are immensely hyper- 
trophied, aud show, under a higher power, a distinct fibrillar structure. The 
nerve-fibres are consequently atrophied, and very few exhibit an envelope of 
myeline ; the immense majority are indicated only by the round, nucleus-like 
body, the axis cylinder. Besides these, there are very numerous nuclei, be- 
longing to the diseased reticulum. Beyond the external layer of reticulum 



66 AUTOPSY OF A CASE OF MANIA. 

are seen two fragments of pia mater, much heavier than normal, and show- 
ing nuclei. 

Section No. 8, made at a point 1 c. above end of cord. The cortical sclerosis 
is here very considerable, the pia mater being remarkably thickened. The 
sclerosis is especially marked at the external end of the anterior fissure. In the 
fissure itself there is thickening of the pia mater, enlargement and thickening 
of blood-vessels ; and around these there is some effusion more granular than 
that occurring higher up, and of a yellowish hue. Opposite the posterior 
fissure the sclerosis is much less intense; but it is again greater over the 
lateral columns. Around the central canal there is some slight condensation 
of tissue, the epithelium is fairly preserved, and there is no effusion in the 
cavity. The effusion which has been seen in so many sections, lying in the 
anterior fissure or occupying the lumen of the central canal, appears quite 
homogeneous, and of a uniform reddish hue, under a power of 100 diame- 
ters. With a power of 340 diameters, we thought that in a few places we 
could make out indistinctly the outlines of red blood corpuscles. We conse- 
quently, though with reservation, consider the effusion as hemorrhagic. 

In none of the many sections examined was any alteration of the nerve cells 
of the gray matter discovered. In some sections the gray matter was seen 
to contain abnormally large vessels filled with blood. 

The state of the spinal cord may be stated in a few w r ords, as follows : 

The organ is in a state of inflammatory irritation, characterized by thick- 
ening of the pia mater, multiplication of its nuclei, and formation of new 
fibrillar tissue in the anterior fissure in various parts of the cord, mainly in 
the upper cervical region and in the lower portion of the lumbar enlargement. 
This morbid state of the pia mater is accompanied everywhere by enlarge- 
ment of blood-vessels and by thickening of their external coat ; in many places, 
besides, by rupture of small vessels, leading to effusion of blood in the bottom 
of the anterior fissure throughout the upper cervical region. In some places 
the central canal is occupied by a similar effusion. In the upper cervical 
region for several c. the left arm of the anterior commissure is broken up by a 
pathological product made up of enlarged vessels, new fibrillated tissue de- 
rived from the pia mater, and by hemorrhagic effusion. Throughout the cord 
there is marked cortical sclerosis. This sclerosis, most marked in the upper 
and lower portions of the organ, has resulted, firstly, in the production of a 
mass of fibrillated tissue containing numerous nuclei, and, secondly, in con- 
secutive atrophy of the nerve fibres lying in the meshes of the reticulum near 
the periphery. In the gray matter, traces of the irritative process are to be 
found in the shape of condensation of the tissue round about the central 
canal, of enlarged blood-vessels, and of one nodule of sclerosed reticulum. 

Medulla Oblongata. — We have been as yet unable to study the state of this 
part in a thorough manner. Sections made at a point .5 c. above the end of 
the calamus scriptorius present the following points : 

The pia mater is somewhat thickened, and contains numerous nuclei. The 
floor of the ventricle is studded with granulations, most abundant and largest 
in the situation of posterior median fissure, having the same fibrillated struct- 
ures as those found on the lateral and other ventricles, a minute description 
of which will be found below. 



AUTOPSY OF A CASE OF MANIA. 67 

The nuclei of the hypoglossal nerves, and the cells of the restiform bodies, 
are normal ; but a little to the outside of and above the hypoglossal nuclei, 
there are seen six or eight nerve-cells in various stages of granuiar degenera- 
tion. Some of them are mere masses of yellow granular pigment. These 
cells belong to the nuclei of the spinal accessory nerves. The vessels of many 
parts of this nervous centre are very large, and nearly all crammed with 
blood corpuscles. In and about the hypoglossal nuclei, vessels measuring 
.15, .1, .06, 0.5 mm. in diameter are found ; in the restiform bodies, vessels 
0.5 mm. in diameter ; and in one section the central part of the left olive 
exhibits a cavity which must have inclosed a vessel measuring .3 mm. 

Ventricular Surface. — "We come now to the study of the most interesting 
lesion of the case, viz., the granular degeneration of the general ventricular 
surface. We shall describe the lesion as it appeared in sections cut from the 
floor of the lateral ventricle perpendicularly to surface, prepared and mounted 
according to Clarke's method. 

(a.) On viewing such a section with various powers, the following points 
are ascertained : The deeper parts of the section exhibit the nuclei of neu- 
roglia in normal numbers, and the ordinary number of blood-vessels, around 
which there is a moderate deposit of yellow granular matter, this being the 
only abnormal appearance. Next, immediately underlying the epithelium, is 
a layer of condensed tissue, contrasting quite sharply with that above de- 
scribed, and measuring, on the average, nearly .5 mm. in thickness. At 
several points, in the neighborhood of blood-vessels, this condensed tissue 
penetrates deeper into the normal brain substance. These vessels, in the 
condensed layer, and in the parts immediately below, are abnormally large, 
filled with blood corpuscles, and their coats are evidently thickened. The 
upper free (spithelial) edge of the section is quite covered with projections, 
these being sections of the granulations whose appearance to the naked eye 
has already been described. These sections vary much in outline and in 
size. Some present a distinct terminal nodule or head, others are cut off 
squarely, a few are pointed, and many are rounded. They range in height 
from a mere nothing to nearly .2 mm. The majority of the granules appear 
opaque, and the opacity extends somewhat, and in various shapes, into the 
subjacent tissue. In some places nothing is visible but a nodule of darker 
appearance than the surrounding/parts, and not actually projecting through 
the limiting line of the section. 

(J).) On viewing one of the non-projecting nodules with an objective mag- 
nifying 340 diameters, it is evident at the first glance that the epithelial 
lining of the ependyma remains over the entire nodule, in a better or worse 
state of preservation ; in some places the nuclei of the epithelial cells can be 
distinctly seen. In reality there are here two nodules lying very near each 
other, a larger and a smaller one, and in the depression between the two a 
certain amount of disintegration has occurred. in the epithelial layer. The 
nodules themselves appear made up of a confused mass of delicate fibrillar 
tissue ; the parts underlying the nodules being made up of similar fibres 
nearly horizontally disposed. The nodules appear separated fromthe other 
tissue by a tolerably sharp outline ; and no cellular elements are visible be- 
neath the epithelium. 



68 AUTOPSY OF A CASE OF MANIA. 

(c.) Examining one of the large projecting granulations, we see that there 
is, as above described, a fibrillated substratum, horizontally disposed. The 
epithelium is preserved on the limiting line or section on either side of the 
granulation, and also for a short distance upon the granulation itself. The 
granulation, made up of fibrillated tissue, the fibrils of which are disposed 
perpendicularly to the edge of the section, projects in such way through the 
remains of epithelium as at once to suggest that the growth has burst through 
the once continuous layer of epithelial elements. Its free edge is made up of 
delicate fibres, and among these are seen the outlines of oval nuclei. In the 
deeper parts of the granulation the fibrillation is more confused, and the 
nuclei no longer distinct. 

(d.) The examination of a minute granulation at its free edge shows a 
number of peculiarly shaped cells, containing very large granular nuclei, and 
having dissimilar ends ; one narrow and thread-like running down into the 
granulation, the other free, rounded, or squared off. A number of analogous 
cells appear faintly outlined in the projecting part of the granulation below 
its free edge. These peculiar bodies are most probably altered epithelial cells 
of the ciliated variety. ♦ 

(e.) The head or projecting part of a granulation being snipped off with 
scissors, is teased to pieces in dilute chromic acid solution (r&oo)? and placed 
under an immersion objective of 1.25 mm. focus made by William Wales of 
Fort Lee, K. J. It is at once perceived that what, under a power of 340 
diameters and excellent definition, appeared as a fibrillar connective tissue, is 
resolved under 1,000 diameters into a congeries of minute nerve fibres, the 
majority of which bear a small quantity of myeline, the others being appar- 
ently naked axis cylinders, or amyelinic fibres, measuring on the average .001 
mm. Nothing whatever in the field resembles fibrillar connective or reticu- 
lated tissue. There arc present lying among the fibres a small number of cells 
and nuclei. Some of the nuclei are free, round, presenting a sharply defined 
outline, measuring from .005 to .007 mm. in diameter, and inclosing a prom- 
inent granule or nucleolus. The cells are ovoid, without membrane, some- 
what granular (not pigmented), and exhibit nuclei similar in size and appear- 
ance to those described above. These cells measure in their long diameter, 
on the average, .014 mm. ; in their short diameter .01 mm. In addition to 
these elements, there are three very peculiar, and we must admit puzzling, 
cells. These bear a resemblance to modified epithelial cells of the type 
described at d, but the long and slender extremities branch in a regular and 
remarkable manner. The heads of these cells present an irregular ovoid 
outline, measure in length about .018 mm., and transversely (short diameter) 
.01 mm. One of them contains a nucleus precisely similar to the nuclei above 
described. The prolongations or tails of the cells present no demarcation 
line from the heads, and taper gradually, giving off two to six branches. 
From the further rounded end of a cell to the second subdivision of its tail, 
is a distance of .07 mm. Some of the smallest branches of these cells, by their 
uniform diameter, .001 to .0015 mm., sharp outline, and homogeneous appear- 
ance, bear the most striking resemblance to amyelinic nerve fibres. 

From this study we think it safe to say that in this patient the ventricular 
lesion was not due, as in Mr. Lockhart Clarke's case, to proliferation of the 



AUTOPSY OF A CASE OF MANIA. 69 

epithelial layer of the ependyma. The preparations all show a very distinct 
sub-epithelial lesion, whether of a truly sclerotic nature we cannot positively 
state. In favor of sclerosis we have the increase of density in the granulations 
themselves and in the underlying tissue to a depth of .5 mm., with thickening 
of the coats of blood-vessels and enlargement of perivascular spaces, in the 
same part. Against this view there may be advanced the absence of modified 
reticulum or neuroglia, which is said * to constitute so large a proportion of 
the ependyma vcntriculorum. Had we contented ourselves with using a 
power of 340 diameters, we should have honestly asserted the existence of 
fibrillar tissue, as making up the bulk of the granulations. The uncertainty 
of our study of this lesion has demonstrated to us the great want of a new 
investigation, with modern objectives, into the normal histology of the walls 
of the ventricular cavity. 

Sections made through the aqueduct of Silvius exhibited granulations of 
precisely similar constitution. It will be remembered that in the preparations 
from the medulla oblongata, granulations of the same appearance were seen 
to spring from the floor of the fourth ventricle. 

The lesion of the general ventricular cavity may be summed up as follows : 
A condensation of the sub-epithelial tissues, with perivasculitis and dilatation 
of the vascular canals, to a considerable depth. A similar condensation 
immediately under the epithelial cells, affecting the form of nodules, which 
nodules in course of growth have burst through the epithelium, and projected 
into the ventricular cavity. In their development these nodules have, further- 
more, set up an irritation in the adjoining structures which has resulted in a 
modification (proliferation ?) of the epithelium itself ; this last being, we 
firmly believe, a secondary and subordinate process. 

Cerebellum. — Nothing ajbnormal is discernible in sections of the convolutions 
of this organ. 

Cerebrum. — Sections cut from one of the convolutions of the right anterior 
lobe, and from one of the inferior part of the right temporo-sphenoidal lobe, 
show no lesion beyond the presence of a few yellowish granulations along the 
blood-vessels. 

"We will only add a few words of an historical nature concern- 
ing the granular degeneration of the ventricular walls. 

First observed by Bayle,t this lesion does not seem to have 
been observed with care until 1861, when Dr. J. Lockhart 
Clarke, J in studying the alterations present in a case of pro- 
gressive muscular atrophy, found the fourth ventricle studded 
with granulations, of which he gives the following concise 
account : 

* Virchow, Cellular Pathology, pp. 311-14 (Am. ed.). 

f Bayle, Traite des Maladies de Cerveau et de ses Membranes. Paris, 1826, 
p. 4G4. (Quoted by Clarke.) 

X Dr. J. L. Clarke and Dr. Gairdner, Relation of a Case of Muscular Atrophy, 
Beale's Archives of Medicine, vol. iii. p. 1, 18G1. London. 



70 AUTOPSY OF A CASE OF MANIA. 

' ' The whole floor of the fourth ventricle, as already remarked, presented a 
very peculiar and unnatural aspect. Instead of being smooth and shiny, as in 
the healthy state, it was entirely paved with a multitude of granulations or 
small rounded eminences, which were very closely aggregated, but differed 
from each other considerably in size. I removed some of them for examina- 
tion, first by scraping them off from the surface, to which they adhered with 
some tenacity ; and then by shaving off a section together with a thin layer 
of the subjacent tissue. When examined by means of a sufficiently high 
magnifying power, the granulations or eminences were seen to consist of 
globular aggregations of the ordinary epithelial cells, which in a natural or 
healthy state, are arranged side by side, and form a smooth or level surface 
on the floor of the ventricle. The tissue immediately subjacent, and which 
consists of exceedingly fine fibres proceeding from the tapering ends of the 
epithelial cells and running in various directions, w T as more abundant than 
usual ; and — as might be expected from the homologous relation of this part 
to that which surrounds the spinal canal — they were interspersed wit!) corpora 
amylacea, but certainly not to a corresponding extent." 

The same granular condition of the ventricular surface was, 
about the same time, attracting the attention of a French alienist, 
M. Joire, who, early in 1861, submitted to the Paris Academy of 
Medicine * a paper in which he stated that he had found this 
condition only in cases of general paralysis of the insane, and 
advanced the view that this was a characteristic lesion of the 
disease. In the Gazette Medicate for 1864, page 528, is an ab- 
stract of a second paper by M. Joire, published in the Bulletin 
Medicate die Nord, in which he describes the appearances to the 
naked eye of these granulations. He states that the parts 
underneath the epithelial layer are softer and more translucent 
than usual. This condition often coincides with dropsy of the 
ventricles, and subarachnoid effusion. In early stages the granu- 
lations are small, numerous, and remind one of grains of sand. 
In old cases the granulations are larger, whitish, or transparent, 
and produce a feeling of roughness under the finger. The lesion 
is most common over and round about the calamus scriptorius. 
Finally, M. Joire claims that the lesion is constant in general 
paresis. In this abstract there is no evidence whatever of the 
microscope having been used. 

Griesinger,t in his classical treatise, merely observes that in 
■ , 

* Joire. Bulletin de 1' Academic Imperiale de Medeeine, seance du 19 Fevrier, 
1861, p. 395. 

f Grriesinger. Traite des Maladies Mentales (traduction du Dr. Doumic). Paris, 
1865, p. 496. 



AUTOPSY OF A CASE OF MANIA. 71 

chronic hydrocephalus the ependyma of the ventricles is very 
often found covered with granulations, thickened and denser 
than normal, and as resisting as leather. 

We find the following in Leidesdorf : * In senile hydrocepha- 
lus there is found a thickening of the ependyma of the ventricles, 
as part of the general thickening of the neuroglia, giving rise to 
a granular appearance. Under the head of new formations this 
author mentions, without details, granulations of the ventricles 
which are derived from connective tissue. 

Maudsley f merely quotes Clarke and Joire, denying the lat- 
ter's assertion concerning the meaning of the lesion. In Dr. 
Blandford's J new book the following passage occurs : 

" Granulations of the lining membrane of the ventricle have been thought 
by M. Joire to be peculiar to general paralysis, which they are not. They 
have been observed, in old- standing cases of mania or dementia, together with 
similar granulations of the pia mater of the parietal and occipital lobes and 
medulla oblongata. They are, no doubt, an aggregated and abnormal con- 
dition of the epithelial cells, and. seem to contain a homogeneous substance, 
probably exuded lymph." 

Eindfleisch § speaks of granulations, like dew-drops, occurring 
on the ependyma of the ventricles, more particularly upon that 
of the fourth ventricle, in cases of chronic hydrocephalus, epi- 
lepsy, masticatory spasm, disorders of speech. He considers 
them as made up wholly of fibrillar connective tissue, and a very 
few cellular elements. 

Finally, we have been informed by Dr. Francis Delafield, one 
of the curators to Bellevue Hospital, that during the last two 
years he has met with this lesion about a dozen times, nearly 
always in connection with granulations in the pia mater. He 
has not, however, made any microscopical examination of these 
products. 

* Leidesdorf , Lehrbuch der psychischen Krankheiten. Erlangen, 1865, s. 256. 

\ Maudsley, The Physiology and Pathology of Mind. Second edition. Lon- 
don, 1868, pp. 455-6. 

X Blandford, Insanity and its Treatment. Am. ed., Phila., 1871, p. 121. 

§ Rindfleisch, Lehrbuch der Pathol ogischen Gewebelehre. Leipzig, 1867-69, s. 
546-7. 



CONTKIBUTIONS TO THE PATHOLOGICAL ANATOMY 
OF THE NEEVOUS SYSTEM.* 

I. Examination of the Cervical Sympathetic Nerve in a Case of 
Unilateral Sweating of the Head. — Some attention has of late years 
been paid to this interesting symptom, and various explanations 
of its mode of production have been offered, t In many cases 
mechanical interference (pressure of tumor or aneurism) with 
the sympathetic nerve is readily made out. In others, the 
patients' antecedents and the results of treatment warrant the 
diagnosis of a sympathetic process, one associated with disorder 
of the stomach or other distant organ. But there are still other 
cases, in which, the above explanation failing, we are obliged to 
have recourse to the unmeaning phrase of idiopathic disorder. 
The instance which I reproduce was of this last kind, and to my 
knowledge is the only one of its class in which a microscopical 
examination of the sympathetic chain has been make. 

The subject observed by me (a male about 50 years of age) 
had exhibited one-sided sweating of the face and neck for a con- 
siderable number of years ; in which period the right half of the 
face and neck never showed any moisture, not even when the 
left side was bathed in perspiration. The abnormality, therefore, 
consisted in the abolition of sweating on one side of the head. 
"When the patient first came under my observation he was in a 
cachetic state, which ultimately proved to be cancerous, an 
abdominal tumor soon becoming apparent. On the evening 
when the patient's wife first informed me of the one-sided 
sweating, he had been suffering severe abdominal pain, and, in 
consequence, was perspiring nearly everywhere. The lower and 
upper limbs and the trunk were moderately moist, the left side 
of the face (forehead especially) was dripping wet ; while imme- 
diately beyond the median line the skin of the right side was 
perfectly dry. The pupils were equal in size and in mobility. 
A careful estimate of the surface temperature on the temporal 

* From the Am. Journ. of Med. Sciences for October, 1872. 
f Consult a good paper on the subject by Roberts Bartholow, M.D., in the 
Quarterly Journal of Psychological Medicine, vol. iii.(1869) pp. 134-144. 



PA THOLOGICAL ANA TOMT OF THE NER VO US SYSTEM. 73 

region of either side was made by means of Dr. E. Seguin's 
surface thermometer, but gave no differential result. 

On the 7th of May the patient died of exhaustion. The 
autopsy was made on the 8th, sixteen hours after death, the 
body having been perfectly preserved in ice. Immense cancerous 
masses were found in the abdominal cavity, affecting principally 
the mesenteric glands. Another deposit, in the shape of a 
rounded tumor as large as a small orange, was met with behind 
the left clavicle, externally to the sterno-mastoid muscle. Micro- 
scopic examination showed the tumor to be composed of carci- 
nomatous tissue. 

The sympathetic chain of the neck was carefully removed on 
both sides, and very shortly afterward immersed in an artificially 
iodized serum. During the dissection it was observed that the 
right nerve was unusually adherent to the sheath of the vessels 
and pneumogastric nerve, from a point on a level with the 
bifurcation of the carotid artery nearly up to the superior 
sympathetic ganglion. The post-clavicular tumor did not involve 
the left nerve in any way. Examination May 9th, twenty hours 
after the autopsy. To the naked eye the right chain exhibits no 
middle ganglion, and presents a marked injection of the nerve 
just above the superior ganglion, in part corresponding to the 
adhesions already described. The left chain appears absolutely 
normal (has three ganglia). 

Microscopical examination of a considerable number of prep- 
arations from the right superior ganglion, teased in serum, or 
stained with carmine : no granular or amyloid bodies can be 
detected, nor any abnormality of the connective tissue ; the 
nerve fibres are normal, and the nerve cells alone depart from 
the healthy standard. This alteration consists in a marked 
increase of the granular yellow pigment, which normally occupies 
one-sixth to one-fourth of the body of the ganglion cells. In 
many cells the pigment is more than equal to one-half the cell 
bulk ; in quite a number it takes up nearly the whole cell body, 
and almost conceals the nucleus. Preparations from that part 
of the nerve which should have presented a ganglion contain 
abundant ganglion cells, nearly all with an abnormal amount of 
pigment. Only a portion of the inferior ganglion remains ; but 
preparations from that show precisely similar appearances. Simi- 
larly prepared specimens from various parts of the nerve trunk 
exhibit perfectly normal nerve fibres, nearly all myelinic, of very 



74 PATHOLOGICAL ANATOMY OF THE NERVOUS SYSTEM. 

variable diameters. No evidence of proliferation of the con- 
nective tissue can be seen. The various vessels met with in the 
above preparations contain large quantities of blood-globules, 
but their coats are healthy. 

Left nerve. — Nearly every part of this chain is examined in 
the same manner ; its nerve fibres, blood-vessels (not injected), 
connective tissue, and ganglion cells appear in precisely the 
same state as similar elements of the right chain, i.e., the first 
three are perfectly normal, the last are very granular. 

Consequently, the only lesion found in these nerves is sym- 
metrically developed, and can, consequently, bear no relation to 
the one-sided arrest of sweating observed during life. In another 
case it would be highly desirable to examine the cervical portion 
of the spinal cord as well as the sympathetic itself. 

The following measurements are obtained from estimating the 
size of very numerous elements on both sides. Ganglion cells 
range from .025 mm. to .062 mm. in diameter ; nerve fibres 
from .001 mm. to .02 mm. 

II. Double Central Canal in part, of an othenuise normal, Spinal 
Cord* — While examining sections from various parts of the 
spinal cord of a patient who had died of the affection known as 
general paresis of the insane, I came across unmistakable evi- 
dences of the existence of two central canals, most distinct in 
the cervical enlargement. 

(a.) In a section made just below the apex of the fourth ven- 
tricle, the central canal is single and open, exhibiting very dis- 
tinct cells. Its long diameter, antero-posterior, equals .53 mm. ; 
its short diameter .052 mm. 

(h.) In a section from a point 3 c. below decussation of pyra- 
mids, a single central canal, blocked up by distorted epithelial 
cells, is seen. 

(c.) Section from the upper part of the cervical enlargement 
shows two small, beautiful central canals, lined with nearly per- 
fect epithelium. The interval between the two canals equals 
.03 mm. The posterior median fissure comes down to a point 
opposite the middle of this interval. The lumen of one canal 
measures transversely .049 mm. ; antero-posteriorly .018 mm. 
The transverse diameter of the lumen of the other canal meas- 
ures .07 mm. ; the antero-posterior .012. The epithelial cells 

* Instances of Double Central Canal. G. Harley and Lockhart Clarke in a case 
of acute myelitis. Lancet, October 3d, 1868, p. 451. 



PATHOLOGICAL ANATOMY OF THE NERVOUS SYSTEM. 



75 



have an average length of about .01 mm. The epithelium is en- 
tirely preserved around the left 
canal, but is a little frayed at the 
inner angle of the right. Between 
the canals is a shapeless mass of 
cellular bodies, such as usually lie 
about the central canal. 

(d.) A section from the lower 
part of the cervical enlargement 
shows traces of two canals, but the 
epithelium is not in as good con- 
dition, and a lumen is distinct only 
on one side. Intervening and sur- 
rounding cellular structure not as 
dense as in (c.) 

(e.) Section from the mid-dorsal 
region exhibits a confused mass of 
cells in the center of the commis- 
sure, with one distinct, irregular 
aperture, and another very imper- 
fect one at a distance of .08 mm. 

(/.) In the lumbar enlargement nothing is found but one 
common cellular (not epithelial) central mass without lumen. 

(g.) At a point 3 c. above end of cord no distinct epithelium 
or canal is visible. 




Diagram of Median Part of Transverse 
Section of Cervical Cord. p. Posterior 
median fissure, a. Anterior median fis- 
sure. 1. Anterior commissure. 2. Pos- 
terior commissure. 3. Central canals 
lined with distinct epithelial cells. 4. In- 
terval filled up with dense cellular struct- 
ure such as surrounds central canal 
usually. 



CASE OF GENEKAL PAEESIS OF THE INSANE.* 

Alexander C , aged 40 years, born in New York, a machinist by occu- 
pation, married. Admitted Jan. '7, 1870. 

History. — His wife states, that about five years ago he had an attack of 
tonsillitis, after which, for a short time, he manifested symptoms of exalted 
mania. Until the date of the illness now reported, his health was, as usual, 
good, but he was more irritable and impatient than formerly. He had been 
employed as skilled workman by the "Weed Sewing Machine Company, at 
Hartford. In August (1869) engaged himself to the Singer Co., in New York. 
This change proved the starting point of a series of extravagant notions and 
excesses, which manifested themselves during the following month. Pre- 
vious to this unusual conduct his wife had no idea that he was not perfectly 
sane. She recollects, however, that for some months before leaving Hartford 
he had manifested, at times, an unusual degree of sexual desire, that he ate 
enormously, complaining afterward that he had not had enough food. 

The priucipal exaltation symptom, which developed in New York, consisted 
in imaginary business connection with James Fisk, Jr., in railroad matters. 
He went to the Opera House to look for him, and once got up and stopped 
the orchestra. Thought that he was heir to A. T. Stewart, and to Astor, 
whose daughter he was to marry. He became intemperate and visited houses 
of ill-fame ; purchased expensive clothing, jewelry, etc., and nearly ran 
through his means in a few weeks. 

On admission to the hospital he had extravagant notions of wealth and of 
power ; was to erect hotels in every city of the world, and to grant any wish 
to anybody and make everybody happy. 

May 29th. — Has once or twice shown violence toward the patients. 

Examination, June 25th. — I copy from my notes : Comes into the room in a 
quick way, unconscious of our presence, exclaiming that he is the greatest 
potentate on earth, the father of Jesus Christ, etc. Is perfectly docile and 
obedient, but every motion is hurried and jerky ; after answering a question 
he constantly and immediately reverts to his exalted ideas. General muscular 
development very good. Heart sounds normal ; percussion and ausculation 
of anterior and upper part of lungs give natural results ; no urinary disorder. 

Head. — Hearing on both sides, fair ; has slight convergent strabismus de- 
pendent on weakness of right external rectus muscle ; pupils, normal in size 
and motion ; has no nystagmus. Vision of left eye good, but denies reading 
time on full-sized watch at a greater distance than 40. cent, with right eye. 
[On July 24th an examination with the ophthalmoscope, by Dr. T. R. Pooley, 
of New York, gives the following results : " Outline of both optic discs irreg- 

* Report of the Pathologist of the Connecticut Hospital for the Insane, Dr. E. C. 
Seguin, for the year 1872. 



CASE OF GENERAL PARESIS OF THE INSANE. 77 

ular ; discs themselves small and white ; vessels, especially arteries, small in 
size. Atrophy subsequent to optic neuritis."] No facial deviation, and none 
of tongue when projected. Frequent fibrillar contractions are visible in orbi- 
cularis palpebrarum, in orbicularis oris, and in levator anguli oris. Speech 
markedly thick, especially so after declaiming — labial souuds affected. Pro- 
jects tongue fairly, and though the organ does vibrate as a whole, there are 
no fibrillar contractions visible in it, and no wrinkling. 

Upper Extremities.— Slight trembling of hands and fingers when extended, 
a vibration being perceived by observer when holding latter slightly between 
his own hands. Xo fibrillar contractions are visible in arms, and none can be 
excited by filliping. Strength very great and about equal jn both hands ; the 
efforts being made in a peculiar, jerky manner. The dynamometer (of Tie- 
mann's make) is too weak to record strength. In the letters which he occa- 
sionally writes, the handwriting appears irregular, but to-day, with care, he 
signs his name in quite a free, firm hand for a man of his station. Sensi- 
bility is normal in its various modes, save that there is a little slowness (senso- 
rial or mental ?) in his perception of heat. Co-ordinates well in executing 
every movement ; eyes open or closed. Measurements of extended arms — 
circumferences, right (middle) 26 c, left 24.3 c. ; forearms flexed at right 
angles, measured near bend of elbow, right 27 c, left 26.5 c. 

Lower Extremities. — Walks well, but in a jerky manner,* produced by 
mental state. Stands and w^ilks securely with eyes open or closed. Right 
leg at thickest part, extended, measures 35.5 c. ; left, 34.5 c. Sensibility in 
its various modes, normal, save that there is a retardation in perception of 
pain and heat. Muscles of entire body exhibit normal electro-muscular 
contractability and sensibility. 

The nurse states that C. never soils his bed or clothing, and that he does 
not masturbate. t His delirium runs exclusively upon greatness and power 
of self. 

Diagnosis. — Chronic diffused peri-encephalitis, or general paresis of the 
insane, in tolerably early stage. 

July 20th. — Has been rather more excited during the past ten days ; is full 
of delusions of an exalted character; articulation more impaired. 

August 2d. — Is, and for several days has been, violent, almost unmanage- 
able. Temperature observations begun. Agitation of hands again investi- 
gated. On holding C.'s extended fingers lightly between our own extended 
hands, a peculiar parchment -like fremitus is communicated to us, apparently 
a result of friction between the contiguous sides of patient's fingers, brought 
about by fibrillar muscular contractions. On comparing this condition with 
that present in a well-marked ease of tremulous hands and head (paralysis 
agitans ?) the following are results obtained : In the case of tremulousness, 
the movements consist in alternate flexion and extension of fingers, due to 
contractions of whole muscles, or of large bundles of fibres ; on holding this 
patient's fingers in the manner above described, no fremitus is perceived, and 
the movements are wholly controlled. 

* This expression refers to action of body as a whole in the act of walking ; 
there was no jerky movement of legs. 

f Another attendant says that patient has masturbated freely. 



78 CASE OF GENERAL PARESIS OF THE INSANE. 

February 19t7i, 1871. — Since last note disease has progressed. Delusion and 
delirium of most exalted sort have continued. Has gradually emaciated. No 
epileptic seizures. Two months ago passed into a well-marked, peculiar 
adynamic state, in which he now lies. A number of decubitus sores have 
developed quite rapidly on several projecting parts. Emaciation is extreme, 
but uniform ; perhaps most marked in face. Eyes in same condition as 
before, right with slight strabismus. Pupils of about normal size (compared 
with those of a healthy person in the same light), right a trifle larger than 
left ; both responding to light. Movements of orbicularis oris slow, stiff, 
but complete. Projects tongue pretty well, without deviation ; organ does 
not appear wrinkled, and trembles but little as a whole ; presents no fibrillar 
contractions. Articulation very imperfect ; he can be understood rarely, and 
with difficulty. Swallowing of liquids fairly performed ; a little cough 
coming on after six or eight spoonfuls have been taken. Xurse reports 
greater trouble than this at times, indicated by "choking spells." Move- 
ments performed by all limbs slowly and feebly. No trace of inco-ordination 
or trembling ; no fibrillar contractions anywhere visible. Sensibility cannot 
be satisfactorily studied. Patient makes no complaint of bed-sores, and ' did 
not call attention to two or three abscesses which formed some time ago. 
Pinching is everywhere felt and complained of, though after some seconds of 
delay. Heart's action exceedingly feeble, though regular ; pulse, 100 per 
minute. Respiration not counted, performed fairly, without rales. Urine 
and freces passed involuntarily, but not unconsciously. Mind is as clear as 
compatible with presence of peculiar exalted delusions, which are still well 
marked — " is the first man born," "has boundless wealth," etc. About the 
middle of the night C. died rather suddenly. 

Autopsy. — Nine hours post mortem (Feb. 20th). Temperature 
of room in which body has lain has been below 10.° C. 
Extreme uniform emaciation. Rigor mortis, moderate. Ulcer- 
ations on under aspect of both elbows, on sacrum, and on spines 
of scapulae. An abscess is discharging on internal face of left 
foot; one, unopened, exists in inner side of left thigh. No 
syphilitic stains. 

Skull and Contents. — Bones healthy. No abnormal adhesions 
of dura mater. Considerable opaline sub-arachnoid on convex- 
ity of brain, compensatory of atrophy of anterior lobes. Veins 
of convexity abnormally full. A large quantity of fluid lies at 
base of brain, and when body is laid prone a fresh gush takes 
place from the vertebral canal. Olfactory ganglia unusually 
firm and gray. Optic nerves appear normal ; so do the third 
nerves. Membranes at base of brain normal. Fifth and other 
cranial nerves normal. Spinal membranes and external aspects 
of cord and medulla oblongata normal. Vertebral and basilar 
arteries are not atheromatous, and contain recent dark clots. 



CASE OF GENERAL PARESIS OF THE INSANE. 79 

The floor of the fourth ventricle appears healthy. Cerebellum 
healthy. Cerebrum : Pachionian bodies moderately developed. 
Marked atrophy of convolutions composing anterior lobes — 
greatest in front. A small amount of fluid exists in the lateral 
ventricles ; their floors are healthy. Opto-striate bodies 
normal. Yarious sections through spinal cord show no abnormal 
appearance . 

Thorax and Contents. — The fifth rib of right side presents an 
old united fracture. Between the sixth, seventh and eighth 
ribs, on left side, are a succession of abscesses, burrowing in 
each intercostal space. Opposite the sixth space the peritoneum 
is firmly adherent. The fibres of the diaphragm are healthy. 

Lungs. — Slight adhesion of entire lower lobe of left lung to 
parietal pleura ; right lung free, except over diaphragm. Some 
fresh adhesions between all lobes of right lung. A few patches 
of lobular pneumonia exist in apex of right lung. The only other 
lesion is a slight congestion of the left lower lobe. 

Heart — Opaque patch with granulated surface on parietal 
pericardium. Yellow appearance of muscular substance in range 
of left coronary artery. On the outer surface of each ventricle 
is a small white patch. The aortic valves are healthy. A firm 
clot exists in aorta' the beginning of which exhibits patches of 
atheroma. Firm clots lie in right auricle ; and a large white 
and black one in left auricle. 

Abdomen and Contents. — Liver pale, slightly bronzed on under 
surface, and presents a number of yellow patches. Gall bladder 
nearly empty, containing a little bile. Liver substance perhaps 
a little fragile. Pancreas healthy. Mesenteric glands unusually 
large. Descending colon, as it lies from the lower edge of 
kidney to the brim of pelvis, is contracted to the size of 
a man's ring finger. Transition from normal to contracted 
portions, sudden. Caput coli and appendix vermiformis nor- 
mal. No obstruction of intestines. Left kidney : its cortical 
portion is broad and whitish ; lymph in pelvis. Eight kidney 
weighs 135. grams ; same as left, but whiter. Suprarenal cap- 
sules are unusually large, 63 mm. long by 31 mm. wide, but not 
diseased. Bladder vascular. Body of left biceps contains a 
rounded tumor. No evidence of periostitis anywhere. 

Eyes removed and placed in Muller's fluid. The sympathetic 
chain in the neck, on either side, is removed, and preparations 
made in artificial serum, and with carmine. These examined 



80 CASE OF GENERAL PARESIS OF THE INSANE. 

with suitable powers of the microscope show none but normal 
nerve cells and fibres, and no increase in the connective tissue 
uniting these elements is noted. Preparations from the sympa- 
thetic in the left side of chest, from the greater splanchnic 
nerve, and from the semilunar plexus give similar results. 

Examination of the Cerebrum after being four days in MulWs 
Fluid. Secondary gyri numerous. Left hemisphere : the con- 
volutions of external surface of anterior lobe are narrower than 
normal, the sulci widened ; these changes being most marked in 
the anterior part of the inferior and middle gyri.* The supe- 
rior frontal gyrus is well preserved, as is the posterior part of 
the inferior, bordering upon the fissure of Silvius. Orbital 
lobule much dwarfed anteriorly. Distance from anterior edge 
of corpus callosum to extremity of anterior lobe is only 33 mm. 
Nothing worthy of note on surface of rest of hemisphere, except 
that the superior gyrus of temporo-sphenoidal lobe (that border- 
ing on fissure of Silvius — posterior marginal of Broca) is atro- 
phied, and that the parietal lobe shows rather wide sulci. On 
section, the gray matter of affected gyri appears more shallow 
than that of the healthy convolutions. No gross lesions are dis- 
coverable in vessels or brain substance. On the right hemisphere 
the same general appearances are exhibited, except that the in- 
ferior frontal gyrus is rather better preserved. Superior gyrus of 
temporo-sphenoidal lobe very small. In parietal lobe, about 
the termination (upper end) of the intraparietal sulcus, anteri- 
orly to postero-parietal lobule, there exists a remarkable inter- 
val between the gyri, quite unlike anything figured as normal 
by Gratiolet. The gray matter of convolutions of anterior lobes 
is as thin as in other half of cerebrum. The apex of anterior 
lobe is even more shortened, the distance from anterior border 
of the corpus callosum to extremity of lobe being but 32 mm. 
No coarse lesions of nerve tissue or vessels can be seen. 

Microscopical Examination of the Nervous Centres. — After seven 
days' immersion in Miiller's fluid, the state of the elements mak- 
ing up the cerebrum is investigated by means of teazed prepa- 
rations stained in carmine, put up in glycerine or in dilute 
chromic acid (one part acid to fifteen hundred parts water). 
(a) Preparation of gray matter of a convolution of the left occi- 
pital lobe shows nerve cells with nuclei, and processes quite 

•"• In this account the classification of convolutions of Prof. Turner, of Edin- 
burgh, is followed. 



CASE OF GENERAL PARESIS OF THE INSANE. 81 

normal ; small vessels and many capillaries filled with blood 
globules, their walls healthy ; no granular bodies or pigment 
masses, (b) Preparation from left anterior lobe; second convo- 
lution above orbital gyrus in great longitudinal fissure, exhibits 
normal (slightly granular) cells and blood-vessels, (c) A speci- 
men from cortex of apex of leffc temporo-sphenoidal lobe shows 
normal nerve cells ; and some few blood-vessels whose walls 
contain scattered granules, (d) In a preparation from the first 
convolution anterior to fissure of Rolando, near longitudinal fis- 
sure, left hemisphere, vessels are found crammed with red blood 
corpuscles ; their coats are healthy, and # there are no granular 
bodies. Right hemisphere, preparations from (a) convolution 
of occipital lobe in great longitudinal fissure, (b) from anterior 
lobe in longitudinal fissure, (c) from in front of fissure of Ro- 
lando, near longitudinal fissure, (d ) from apex of temporo-sphe- 
noidal lobe, show nothing abnormal except the presence of a few 
(scattered) granules in the walls of many vessels, including capil- 
laries. Preparations from the middle of the corpora striata 
exhibit abundant yellow granular deposit in coats of blood- 
vessels, in the adventitia, and in the perivascular space ; the 
nuclei of many capillaries are granular. Many vessels are filled 
with blood. 

Examination of the Hardened Nervous Centres. — The spinal cord 
was cut into pieces about two centimeters in length, and sus- 
pended in a chromic acid solution (one part to five hundred) for 
about six weeks, when it was transferred to strong alcohol. 
Sections were subsequently cut from these pieces, stained with 
carmine, soaked in alcohol and in absolute alcohol, cleared up 
in oil of cloves, and mounted in a solution of Canada balsam in 
chloroform. Many sections from each of the points specified 
below are carefully studied with low and high powers of the 
microscope, (a) Sections from a point 3 c. below decussation of 
pyramids, (b) from the upper part of the cervical enlargement, 
(c) from the lower cervical region, (d) from the mid-dorsal region, 
(e) from the lower part of the lumbar enlargement, and (f) from 
a point 3 c. above termination of cord. These preparations ap- 
pear normal in every particular. No trace of granular bodies 
can be found (posterior columns being searched with especial 
care), the nerve cells, the nerve fibres, and neuroglia are every- 
where normal. The medulla oblongata is examined in sections 
made at the following points : (a) at the apex of the fourth ven- 
6 



82 CASE OF GENERAL PARESIS OF THE INSANE. 

tricle, (b) through the middle of the olivary bodies, (c) 5 mm. 
below lower edge of pons Varolii, (d) 3 mm. below edge of pons, 
through striae of auditory nerve, (e) 2 mm. below edge of pons, 

(f) through lower part of pons, showing nucleus of sixth and 
seventh nerves. These sections present nothing whatever ab- 
normal, except a slight dilatation of some of the largest perivas- 
cular canals. The brain was left in a mixture of bichromate 
of potassa and an uncertain quantity of a solution of chromic 
acid (one part to one hundred). After several weeks the 
pieces of the different lobes of the brain were transferred to 
strong alcohol. [I may here state that in cutting the brain to 
prepare these pieces, no gross lesions were found in any central 
part.] Sections were cut from the hardened pieces, including 
the pia mater wherever possible, and treated in the same way as 
the cord sections. Many of these preparations are attentively 
studied, with the following meagre results : (a) Preparations 
from the convexity of right hemisphere, near the termination of 
fissure of Rolando, at the great longitudinal fissure. Pia, torn 
off; nerve cells, normal; many perivascular spaces enlarged, 
but containing no pathological products ; vessels themselves, 
and neuroglia, apparently unchanged ; no granular or amyloid 
bodies, (b) Preparation from the right anterior lobe ; pia 
evidently much thickened, with production of much fibrillar con- 
nective tissue and many nuclei ; in the pia meshes there may be 
seen scattered yellowish pigment masses, which bear no definite 
relation to the blood-vessels ; the nuclear new formation is 
especially abundant about the vessels. The gray matter exhibits 
vessels which have lymphatic sheaths rather narrower than 
usual, and within the sheaths lie a few pigment granules. Nerve 
cells and neuroglia appear normal. White substance contains 
capillaries and larger vessels gorged with blood corpuscles; 
none of the capillaries showing any degeneration of their nuclei. 
No recognizable changes in neuroglia and nerve fibres, (c) Prep- 
arations from the orbital convolution of the right anterior lobe, 
exhibit essentially same lesions as above. In addition, some 
vessels of the cortex are tortuous in their sheaths, (d) Sections 
from the left anterior lobe (different part) present alterations 
similar in kind and extent, (e) Preparations from the apex of 
occipital lobe appear absolutely normal. (/) Sections from the 
convolutions of the cerebellum present a normal appearance. 

(g) Sections made perpendicularly to the floor of the lateral 



CASE OF GENERAL PARESIS OF THE INSANE. 



83 



ventricles show epithelium and underlying layer absolutely 
normal, (h) Transverse sections of third nerve (motor oculi) are 
normal. Dr. Delafield reports that the optic, nerve is absolutely 
normal, and that the eyeball presents no alterations worthy of 
note. 

The following measurements of the patient's temperature, 
pulse, and respiration were made by Dr. W. B. Hallock, as 
near as possible to the hours of 9 A.M. and 5 p.m. 




INFANTILE SPINAL PAKALYSIS.* 

Gentlemen :— I think that you may obtain a clearer idea of 
the importance of infantile spinal paralysis if we study it not 
separately, as I had at first purposed we should, but as one of 
the forms of paralysis to which infants are liable. At a sub- 
sequent meeting we can briefly inquire into the other varieties 
of infantile palsy, and you will then obtain a knowledge of a 
great part of the nervous pathology of infancy, and be better 
prepared to diagnose the most important of these affections — 
infantile spinal paralysis. The period of life termed infancy is 
that which includes the first dentition to the beginning of the 
seventh year. The pathology of this stage of existence is treated 
of separately by authors, in part because of the peculiar dif- 
ficulties in diagnosis presented by children of this age, and in 
part because of numerous peculiarities they exhibit, such as 
susceptibility to the action of causes of disease, of medicines, and 
the exaggeration of certain groups of symptoms, such as the 
spasmodic element in the sphere of the nervous system. There 
is no essential difference, please remember, between infants and 
adults in the nature, course, and treatment of disease. 

The following synopsis represents the principal forms of 
paralysis which are likely to occur in infancy, together with 
their leading pathogenetic factors : 

PAKALYSIS IN INFANCY. 

1. Hemiplegia (clot, injury, embolism, tumor in brain). 

2. Paraplegia (injury, clot, inflammation of cord). 

3. Peripheral paralysis (compression, etc., of nerve trunk). 

4. Inhibitory paralysis (peripheral irritation). 

5. Infantile spinal paralysis (atrophy of motor nerve cells). 

The last of these is the disease we shall study to-day, and 
several examples of it are before you, affecting subjects of 
different ages. The term which I have adopted is one of 

* From the Medical Becord, N. Y. 1874. A lecture delivered at the College of 
Physicians and Surgeons, New York, on Nov. 8th, 1873. 



INFANTILE SPINAL PARALYSIS. 85 

numerous synonyms by which the disease has been known. The 
first systematic writer upon the subject, Heine, used a corre- 
sponding German name, spinale Kinderlahmung, in his second 
edition of 1860. French writers upon the diseases of infancy, 
who studied the subject very thoroughly in its clinical aspects, 
Eilliet and Barthez,* denominated the disease paralysie essentielle 
de Venfance. Bouchut, entertaining a very singular notion of the 
pathology of the affection, gives it the name of paralysie mioge- 
nique. Memeyer retains the term essential paralysis, considering 
it as a safe one to adopt during the present unsettled state of 
opinion upon the question of pathology. The word essential is 
used by these authors as equivalent to functional, or sine materia. 
The title infantile paralysis is one employed by such authors as 
C. B. Radcliffe and Adams. Duchenne, in the last edition of his 
work on electrization, calls the disease paralysie atrophique de 
Venfance, instead of paralysie atropldqiie graisseuse de Venfance, as 
in his edition of 1860. Hammond, in his treatise upon Diseases 
of the Nervous System, speaks of organic infantile paralysis. 

SYMPTOMS AND COUESE OF THE DISEASE. 

In brief infantile spinal paralysis may be defined as an acute 
febrile affection, resulting in generalized paralysis, which shortly 
disappears from all but a limited part of the body, where the 
akinesis persists indefinitely without impairment of sensibility, 
is accompanied within a few weeks by atrophy of the palsied 
muscles, and is followed later by various deformities — the result 
of altered balance of power at certain joints. The anatomical 
lesion of the disease consists in primary (?) atrophy of the 
nerve cells of the anterior horns of the spinal cord (motor tract), 
and in secondary (?), complicating (?) myelitis. 

There are three quite distinct stages in the course of infantile 
spinal paralysis. 

(a) The Febrile Stage. — A child, and usually a healthy or even 
a robust child, has an indisposition, with febrile movement, 
evidenced by restlessness or drowsiness, hot skin and frequent 
pulse. The mother's attention is often called to a co-existing 
local affection, such as indigestion, intestinal catarrh, or morbid 
dentition. The last is the usual condition referred to, because 
the age when infantile spinal paralysis is most apt to occur (six 
to twenty-four months) includes nearly the whole period of 

* Rilliet et Barthez, Maladies desEnfants, t. ii., p. 545 et seq. Paris. 



86 INFANTILE SPINAL PARALYSIS. 

dentition, and because mothers as well as many practitioners 
are only too willing to hold the teeth responsible for any disease 
which may arise during their evolution. The fever has not, to 
my knowledge, been studied with the thermometer. Fever 
has been observed in nearly all cases * (forty out of fifty). 
When parents assert that no fever was present at the outset, it 
must be borne in mind that a certain degree of intelligence is 
required to enable a person to recognize fever ; that in some 
cases only skilled observations (thermometrical measurement) 
will reveal its existence ; and that it may have been present for 
a few hours only. Besides these phenomena, there are several 
nervous symptoms present in a certain proportion of cases, 
convulsions, usually not involving the facial muscles, and de- 
lirium. Hyperesthesia is also present ; but whether this is a 
true hyperesthesia, or an evidence of that morbid sensitiveness 
which is part of the febrile state, remains uncertain. 

(b) Stage of Paralysis— -As the fever subsides, the mother, 
upon handling the child, discovers that voluntary motion has 
been lost in nearly the entire body. The exact period when the 
akinesis appears, and whether it develops slowly or suddenly, are 
points not yet investigated. The paralysis is at first generalized, 
often involving all the limbs, very rarely the face. At the same 
time no impairment of sensibility is to be noted. In a short 
time, a few hours, the paralysis recedes from some parts and 
persists in others ; it being very rare that more than one half of 
the body remains palsied. This retrocession of the paralysis, 
its disappearance from some limbs, and fixation upon one or 
two, or upon unsymmetrical distant muscles, is highly charac- 
teristic of the disease — I might almost say pathognomonic. 
This fixation is usually upon parts of the lower limbs, more 
seldom upon the upper, and rarely upon parts of the trunk. In 
only one case has a muscle of the head been found definitely 
paralyzed — the temporal. The muscular group which is most 
often affected is the anterior tibial and peroneal. Owing to the 
immunity of the abdominal muscles, the bladder and rectum 
perform their functions. 

(c) Third Stage. — Inseparably connected with the definitive 
akinesis is the muscular atrophy, with loss of electro-muscular 
contractility, and with deformities. The loss of irritability in 



Laborde. De la paralysie (dite essentielle) de l'enfance. Paris, 1864, p. 3. 



INFANTILE SPINAL PARALYSIS. 87 

palsied muscles, as tested by the electrical current (faradic), 
occurs very early — at a period varying from one to six weeks. 
In one case atrophy and loss of electro-muscular contractility 
were well marked on the fourth day (Laborde*). A very few 
years ago three observers independently made the very valuable 
observation that these atrophied muscles could be made to con- 
tract by the application of the galvanic current. Mr. Harry 
Lobb, f Dr. "William A. Hammond, % and Mr. J. Netten Kad- 
cliffe § (from 1863 to 1865), are each entitled to the merit of 
making this observation in infantile palsy. The application of 
this reaction to the galvanic current to prognosis will be stated 
further on. 

The atrophy of the muscles is both relative and positive, and 
is accompanied by certain histological changes, which will be 
detailed when we study the morbid anatomy of the disease. In 
the case now before you, a young man seventeen years old, in 
whom infantile palsy set in at the age of twenty months, the 
bones of the legs, themselves much reduced in size, seem covered 
only by skin and a little adipose tissue. These legs also ex- 
hibit two accompaniments of the atrophy of infantile spinal 
paralysis, viz., imperfect circulation and diminished temperature. 
The atrophied parts are very purple, and are quite cold to the 
touch. The diminution of temperature has been measured by 
Heine,! and .found very great ; the atrophied region in one case 
having a surface temperature of only 17° C. This is in striking 
contrast to the temperature of limbs palsied by a cerebral lesion. 

In consequence of this akinesis, indefinitely prolonged, accom- 
panied by wasting of the muscular tissue, there are formed a 
number of deformities. Some of these consist merely in arrested 
development, as indicated by the shortening of the affected limb 5 
there occurs a relative atrophy. The shortening of a limb, a 
lower limb more especially, gives rise to secondary deviations 
in forms, such as twisting of the pelvis and lateral curvature of 
the spine. These secondary deviations, which are the result of 
attempts to restore disturbed equilibrium, are called compensa- 



* Laborde. Op. cit., p. 19. 

f In a letter to London Med. Times and Gazette, 1863, Vol. ii., p. 682. 
% New York Medical Journal, Dec, 1865, Vol, ii., p. 168. 

§ Ref. by C. B. Radcliffe, in Reynolds's Syst. of Medicine, Vol. ii., art. on In- 
fantile Paralysis, p. 665. London, 1868. 

\ Heine. Spinale Kinderlahmung. Stuttgart, 1860, p. 16. 



88 INFANTILE SPINAL PARALYSIS. 

toiy. It is important to distinguish these compensatory deform- 
ities from the primary, or truly paralytic ones, because the 
treatment of either kind differs radically. The positive deform- 
ities are caused, as stated in the definition, by impairment in the 
balance of muscular power about any articulation. For example, 
in the feet of one of the patients before you, you see an example 
of deformity which constitutes the talipes equino-varus of sur- 
geons ; toes point downward and inward. The anterior and 
posterior muscles of the legs are palsied and atrophied, and 
consequently the feet obey the laws of gravity, dropping into 
their position because the ankle joint is well back upon the pos- 
terior third of the feet. There is no resistance to passive move- 
ment in all directions. In other cases only one set of tibial 
muscles is paralyzed, and the deformities are produced by the 
unchecked (unantagonized) action of the healthy muscles. In 
the feet we may thus have talipes equinus (" the most common 
and important variety," Erichsen), or talipes equino-varus, or 
any of the varieties which you will find fully described in surgi- 
cal text-books. In a case of talipes equinus of this sort we find 
great resistance to any attempt at overcoming the deformity; 
the tendo Achillis is very tense. The muscles governing the 
movements of the knee joints may be paralyzed, and in conse- 
quence we obtain analogous deviations at that joint. About the 
upper extremities the deformities are less striking, but are pro- 
duced by the same double mechanism, obedience of parts to 
gravity, and unchecked action of certain muscles. The spinal 
deformities are nearly always of the compensatory sort : for in- 
stance, a shortened leg necessitates the inclination of the pelvis 
to the side on which the shortening is ; and in order to preserve 
the equilibrium of the body, the lumbar vertebrae bend so as to 
form a concavity on the opposite side, and higher up there 
occurs a secondary spinal curve to the side of the shortened 
limb. The lateral curvature is known technically as scoliosis. 
This is rarely duo to palsy of spinal muscles, though I have now 
under treatment a case of this primary paralytic scoliosis. A 
variety of muscular disorders may cause scoliosis in individuals 
not affected with infantile paralysis. (Consult the various works 
on deformities.) Other spinal deformities, more often primary, 
are the bending forward of the spinal column, non-angular, 
called kyphosis ; and the bending backward, termed lordosis. The 
bending forward is shown in a minor degree (quasi-pathological) 



INFANTILE SPINAL PARALYSIS. 89 

in what is termed stooping — a supposed sign of studious habits. 
Lordosis, as first clearly pointed out by Duchenne, may be due 
to palsy of the abdominal muscles, or to bilateral palsy of the 
lower spinal extensors ; in both cases the upper part of the body 
is thrown unnaturally backward to preserve equilibrium. The 
two forms may be recognized without a minute examination of 
the seat of palsy, by using a plumb-line. Dropping the line 
from the shoulders, it will clear the sacrum in cases of lordosis 
due to palsy of the erectors of the spine ; whereas in palsy of 
the abdominal muscles it will fall within the sacrum. In the 
latter case there is a deepening in the normal lumbar curve 
without positive backward projection of the upper part of the 
body.* 

One word more concerning the genesis of primary deformities. 
It is often said that in club-foot and other deformities, the 
efficient cause of the deviation is spasm of the preponderating 
muscles. This I believe to be extremely rare, and a belief in 
this erroneous doctrine leads to insufficient (merely orthopaedic) 
treatment of the deformities. 

Changes in nutrition in the paralyzed parts ; many of these, as 
observed in the disease, consist in what may be termed relative 
atrophy, i.e., arrested development or retarded growth, e.g., 
diminution in the calibre of the blood-vessels, not only of the 
parts affected, but extending further into the vessels above the 
atrophied muscles, and even into the main trunks. In a certain 
number f of cases of atrophied lower extremities, a marked dim- 
inution in calibre lias been found to exist in the iliacs, and even 
in the lower portion of the aorta. In the boy before you, with 
extreme atrophy of all the muscles below both knees, the whole 
vascular system of the lower extremities is abnormally small. It 
is necessary to bear in mind that no pathological change is dis- 
coverable in the walls of these vessels ; it is an excellent example 
of simple arrested development. Again, we find the bones of 
the implicated regions diminished in size, the arrested develop- 
ment affecting rather their circumferential than their longitudinal 
growth, only a slight shortening being found to exist even in 
cases of long standing. Let us now devote a few moments to the 
study of the more positive changes in nutrition, as exhibited in 

* Duchenns. Da l'Electrisation loealisee. 3me ed. Paris, 1872, p. 498. 
f Case by Charcot and Joftroy. Archives de Phys. normale et pathol., 1870. 
Tome 3, p. 134. 



90 INFANTILE SPINAL PARALYSIS. 

the muscles. The morbid anatomy of the muscular system in 
infantile spinal paralysis has been the subject of laborious and 
careful investigation, and the results of the latest researches tend 
to convince us of the existence of different kinds of muscular 
degeneration, though by no means of equally frequent occur- 
rence, in this disease. By far the most common form is : (a) the 
simple atrophy, a form which almost always affects such muscles 
as are kept in forced repose for a long period ; it manifests itself 
in a shrinking of the individual muscular fibres; a transverse 
section reveals the separation of the contractile substance proper 
from the sarcolemma ; moreover, as a rule, we find a fatty infil- 
tration of the cells of the connective tissue, (b) A granular 
degeneration is described as succeeding in order of frequency. 
In this form proteinaceous granules (bodies unaffected by ether, 
dissolved by acetic acid) are found in the fibre itself; the stria- 
tion disappears gradually, more slowly than in the simple atro- 
phy ; as in the latter form, a fatty infiltration of the interstitial 
tissue also exists, (c) A true fatty degeneration is believed to 
be comparatively rare. The earlier belief, that it constituted 
the peculiar muscular lesion in infantile paralysis, aside from its 
occasional occurrence, may have arisen from the almost unex- 
ceptional co-existence of the interstitial fatty changes with the 
forms above described. 

. Pathological Anatomy. — We have now to consider the morbid 
anatomy of the disease itself. By the earlier writers it was be- 
lieved to be essentially functional in its character. The first step 
toward giving us a clearer conception of the true nature of the 
affection was made by Heine, who published the results of his 
observations in 1840 ; discarding the functional theory, he ex- 
pressed his belief that the disease was due to a violent congestion, 
with perhaps a subsequent inflammation of the nervous centres. 
Later, cases were published by Laborde and Cornil, in which a 
sclerosis of the anterolateral columns was described. In an 
autopsy by Echeverria, sclerosis and amyloid degeneration of 
the antero-lateral columns, sclerosis of the anterior nerve roots, 
and brown pigment in the nerve cells, were found. In a case of 
von Eecklinghausen's, tubercular deposit was discovered in the 
substance of the cord. H. Koger and Duchenne, Jr., reported 
two cases in which autopsy revealed atrophy of the anterior and 
antero-lateral columns, diminution in size of the nerve fibres, in- 
crease of the interstitial connective tissue, and the presence of 



INFANTILE SPINAL PARALYSIS. 91 

numerous amyloid bodies. In an unrecognized case of infantile 
paralysis, Mr. J. Lockliart Clarke, of London, described an atro- 
phy, a degeneration of the cells of the anterior horns. 

To Prevost (a pupil of Charcot's), therefore, is due the credit 
of first recognizing this cell degeneration as the true lesion in 
this disease. In 1866 he published the report of the autopsy in 
which this lesion was discovered ; since that date a number of 
cases have been reported by Charcot and his pupils, in which a 
similar cell degeneration has been found. Studied with the 
microscope, we find that it consists in an increase of the normal 
pigment of the nerve cells ; the latter are observed to become 
densely packed with pigment granules ; and finally, to wholly 
lose their cell character. In their place a simple granular mass, 
which gradually undergoes a marked diminution in size, is seen. 
In a certain number of cases no granular change is discoverable, 
the cells seemingly being subjected to a simple wasting process. 

Other morbid changes indicating a myelitis, have been de- 
scribed as among the lesions of infantile paralysis, e.g., a scle- 
rosis, an increase of the interfibrillar connective substance of 
the medullary columns, with a marked increase in the nuclei of 
that substance ; the formation of cavities in the gray matter, 
apparently through a process of liquefaction ; small clots in the 
same substance ; corpora amylacea in both the gray * and white 
matter ; and finally what can only be described as condensed 
patches of tissue in the former. 

The question is yet disputed whether the granular cell de- 
generation is to be regarded as the primary lesion. The fact 
that in one case at least t the cell lesion has been observed 
without any concomitant myelitis, would seem to support Prof. 
Charcot's view that the cell degeneration is the primary and 
essential lesion. This is further strengthened by the recent rev- 
elations concerning the state of the nervous centres in progress- 
ive muscular atrophy ; in that disease the cells of the anterior 
horns being found in part or wholly destroyed by a similar pig- 
mentary degeneration, without surrounding myelitis. 

Prof. Charcot was so kind as to give me some sections of the 
cord from the case, now classical, which he published under his 
own name and Joflroy's (his interne) in 1870. I will pass around 

* The theory now gaining ground in regard to the character of these bodies is, 
that they are due to an amyloid degeneration of the round cells of the neuroglia, 
f Case by Charcot and Joffroy. 



92 INFANTILE SPINAL PARALYSIS. 

microscopes, each armed with a low objective, one showing a 
transverse section of a normal spinal cord, the other the sec- 
tion from Charcot's case. Both sections are from the mid-dor- 
sal region of the cord, a part in which the anterior horns are 
small and the cells few. The normal anterior horn exhibits six 
or eight large, well-defined multipolar ganglion cells, stained red 
by carmine, their nuclei standing out more deeply tinged than 
the body of the cell. On the other hand, careful examination of 
the morbid section shows nothing but a somewhat condensed 
gray horn-tissue, without one distinct ganglion cell. The granu- 
lations which probably once existed in the place of some of the 
cells have been dissolved by the method (Clarke's) used in pre- 
paring the section. I would also call your attention to the fact, 
that the diseased anterior horn is shrunken and less club-shaped 
than the same part in the healthy section. 

The diffekential diagnosis of this from othar paralytic affec- 
tions of infants I leave until our next meeting, when we shall 
review the whole group briefly. 

The pkognosis of infantile spinal paralysis is not good, for 
many reasons. The disease is a severe one, accompanied by a 
serious central lesion, and is possibly incurable in a certain pro- 
portion of cases in spite of every favoring circumstance. Then 
usually we are consulted weeks, months, and even years after 
the stage of atrophy and deformity has set in, and the cure is 
then more questionable in proportion to the period of time 
which has thus elapsed. Many of the deformities can be rem- 
edied, at any age, by proper orthopaedic treatment ; but that is 
not curing the disease. Until the recent (see supra) discovery 
of the reaction of atrophied muscles we had no guide in prog- 
nosis beyond time, and the appearance of the parts. Now we 
know that if any contraction can be obtained by means of the 
galvanic current (interrupted), there is some hope of restoring 
the muscles to activity. One authority (Dr. Hammond) * says : 
" If the muscles can be made to contract with either the induced 
or the primary currents, the cure is merely a matter of time and 
patience ; " but I am afraid that this is rather a sanguine ex- 
pectation. I should give a very guarded prognosis, under these 
circumstances, in all cases having lasted beyond a year. 

I will be very brief about the treatment. The management of 
the first or febrile stage is a matter of uncertainty ; few prac- 
* A Treatise on Diseases of the Nervous System. New York, 1871, p. 692. 



INFANTILE SPINAL PARALYSIS. 93 

titioners see the cases in this stage, and when they do, the diag- 
nosis of single fever, or of fever symptomatic of some teething 
or intestinal disorder, is usually made. Were I to meet with 
such a case, and have due reason, from occurrence of delirium, 
convulsions, and the presence of hyperesthesia, to suspect im- 
pending spinal palsy, I should leech the child's spine, and apply 
counter-irritants to the extremities. Besides, treatment indi- 
cated by the state of the mouth or bowels should be carried out. 
The treatment of the second stage is likewise a matter about 
which no rules based on solid experience can be laid down. I 
should favor irritating the spine and the extremities, keeping 
the child's bowels free, and applying electricity, in either of the 
forms commonly employed, to the palsied muscles. 

The management of the third stage may be divided into (a) 
the treatment of the central lesion and of the atrophy"; and (6) 
the curing of the deformities. 

(a) We know no means which will with certainty remedy the 
central lesions which I have described as existing in this disease. 
Strychnia and nux vomica were prescribed by Heine and by 
other older authorities, but are now abandoned. The hypoder- 
mic injection of strychnia about the wasted parts has been rec- 
ommended of late, and is worthy of a trial ; from .001 to .004 
may be injected with safety, according to the age of the patient. 
Of course everything which shall tend to improve the patient's 
general condition (hygiene, nutritious food, cod-liver oil, exer- 
cise) will favor the reconstruction of the atrophied nerve cells. 
The means of treating the palsy and atrophy consisted, until a 
few years ago, in the (nearly always vain) application of the far- 
adic current, cold and hot douches, and the systematic friction 
of the atrophied muscles. These last are valuable, especially the 
alternate use of ice (or cold water) and hot water to produce 
hyperemia. Beyond these in value comes the use of the gal- 
vanic current, which will in many cases produce good contrac- 
tions in the wasted muscles. The number of cells to be used 
must be determined by trial, 10 — 20 — 30 elements of Stohrer's 
battery may be required to obtain a reaction. The positive 
electrode should be placed upon the nerve-trunk supplying the 
atrophied group of muscles, and the negative sponge upon va- 4 
rious muscles of the group ; the current being meanwhile inter- 
rupted slowly by removing and replacing the negative electrode, 
or (to produce maximum irritation) reversed as well as inter- 



94 INFANTILE SPINAL PARALYSIS. 

rupted by a mechanical contrivance on the battery or in the 
hand. I would suggest the use of nitrous oxide gas for the pur- 
pose of avoiding the intense pain produced by a large number 
of cells. Especially is anaesthesia useful in the first examination 
when you want to base a prognosis upon the result. An advantage 
offered by the use of this adjunct is, that the child being still, 
you are able to recognize a small muscular contraction which 
might be overlooked during the struggles of the suffering patient. 
How difficult it is to be sure that contractions occur under these 
circumstances, those of you who have attended in the electrical 
room of the college will remember. I am led to make a remark 
which I should have made when speaking of the prognosis, to 
the effect that a safe negative prognosis cannot in my opinion be 
based upon a first or second galvanic examination. If you can 
afford the time, and your patient the money, you should ask for 
a number of trials, at least six, before saying that the patient 
cannot be cured or improved. A great difficulty in the way of 
proper and successful galvanization consists in the very common 
stretched state of the atrophied muscles. For instance, in a 
palsied leg with healthy posterior tibial muscles, there exists a 
pes equinus, and in consequence the wasted anterior tibial 
muscles are stretched to a great degree. Now, gentlemen, I be- 
lieve that this tense condition will prevent galvanic reaction for 
a long time, if not indefinitely ; and the relief of the tension 
either by a mechanical contrivance (shoe), or better still by a 
tenotomy and a shoe, is followed by success in treatment. In il- 
lustration I would cite a private case of my own, a lady suffering 
from symptomatic muscular atrophy consequent upon cerebro- 
spinal meningitis, in whom the muscles of the legs were in much 
the same state as the muscles in cases of infantile spinal palsy ; 
the posterior tibial muscles having in part recovered. The 
anterior tibial muscles were kept tense by a strong pes equino- 
varus, and for several months careful galvanization (even elec- 
tro-puncture) produced no reaction. At last, as a dernier ressort, 
I asked Dr. H. B. Sands to cut the tendo Achillis in both legs, 
and to put the limbs in plaster of Paris. This was most dex- 
trously done, and four days after the tenotomy distinct contrac- 
tions appeared under galvanization in the atrophied muscles. 



INFANTILE SPINAL P ABA LYSIS. 



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A CASE OF TBAIDIATIC BRACHIAL NEURALGIA 
TREATED BY EXCISION OF THE CORDS WHICH 
GO TO FORM THE BRACHIAL PLEXUS.* 

We offer the following case, believing it to be unique in its 
causation, and in the means used to relieve the terrible suffer- 
ing caused by the nerve lesion. 

History of the Case. — E. McA., an American, aged 18 years, was wounded 
in the following manner, at Worcester, Mass. On the 4th of July, 1871, 
he was aiding in firing a salute with a brass cannon. "While he was ramming 
home the charge, standing on the right of the piece, his left hand by his side, 
and his right hand driving in the rammer, the piece was prematurely dis- 
charged. He was thrown a considerable distance (seven meters), and lost 
consciousness. In five minutes consciousness returned, and an examination 
showed no injury of any part excepting the right upper extremity, which 
exhibited a badly lacerated wound of the thumb and hand, a fracture of both 
bones of the forearm in the lower part of its middle third, and an extensive 
burn of the same part. Patient states in the most positive manner that his 
hand was absolutely without sensation at the time he regained consciousness, 
and remained t; dead."' Very shortly after the accident the metacarpal bone 
of the thumb was disarticulated, and as careful a dressing made of the fract- 
ured forearm as was allowed by the extensive burn. He was under the care 
of Dr. Albert Wood. 

All apparently went on well until about three weeks after the accident, at 
which time pain showed itself in the range of distribution of the ulnar nerve 
of the injured side. In a few days this pain became constant, and assumed 
an extreme character, extending to the thenar eminence, and affecting the 
minimus and annulus fingers severely, the medius moderately ; the pain was 
a cutting and tearing one. From that period neuralgia has been the predom- 
inant symptom, depriving the patient of rest, exhausting him physically, and 
quite breaking down his moral tone. Meanwhile, the wound resulting from 
the amputation of the thumb had partially healed, but no union had taken 
place between the fractured bones. 

On the 11 th of August the patient was brought to this city, and was 

* By E. C. Seguin, M.D., in collaboration with Henry B. Sands, M.D. From 
the Archives of Scientific and Practical Medicine, Jan. 1873. 

The operation in this case was planned by Dr. Seguin, tried on the cadaver by 
Prof. John G. Curtis, then demonstrator of anatomy, and performed with well- 
known skill by Prof. Sands. For a similar operation, see Drs. Maury and Duh- 
ring in the Am. Jr. Med. Sciences for July, 1874. [R. \Y. A.] 

7 



98 CASE OF TRAUMATIC BRACHIAL NEURALGIA. 

attended by Dr. Salvatore Caro. Under this gentleman's care, narcotics, 
morphine, chloral, chloroform, were judiciously administered, but the con- 
trolling effect of these drugs was very fugitive ; the moment that the 
patient awoke from artificially produced sleep, the neuralgic pain in the 
hand and fingers reappeared with extreme violence, and caused the sufferer 
to groan and shriek. The wound caused by amputating the thumb rapidly 
healed, and the burn likewise cicatrized in greater part. From day to day 
the pain seemed, however, to grow worse, and the patient's strength and 
moral tone to fail. He became so irritable that the dressing of the wounds 
was a most difficult matter, inasmuch as he thought movement of the shoulder 
and arm increased his suffering. 

On the 14th of August, Dr. Caro called Dr. Sands in consultation, and the 
other author of this report was allowed by the courtesy of these gentlemen to 
take part in the examination. The following memorandum is a copy of notes 
taken shortly after the consultation by Dr. Seguin. 

The patient is a well-built, muscular man, much emaciated. During the 
examinations he exhibits a truly extraordinarily nervous state, which his 
friends declare is quite unlike his usual manner. The face exhibits the traces 
of severe suffering and broken sleep. The right upper extremity is the seat 
of slight oedema. In the lower middle third of the forearm is a false joint, 
caused by the non-union of the fractured ulna and radius, the ends of which 
are considerably displaced. Nothing remains of the burn except a granulat- 
ing surface, perhaps 3. cent, in diameter, on the inner surface of the lower 
third of the forearm. The amputation at the thumb-joint has left a small 
healthy oval ulcer. The entire upper extremity is motionless upon a pillow, 
the elbow and forearm being loosely supported by a simple felt gutter-splint. 
Patient fears that the examination will increase the intense shooting, burning 
and tearing pain which affects the fingers and the hand ; he dreads contact, 
active and passive motion. Consequently we are surprised to discover that 
(a) patient can make no voluntary motion of any part of the right upper ex- 
tremity, except slightly raising the scapula, and that (b) sensibility is com- 
pletely abolished as high as the upper part of the arm. The limit between 
absolute anaesthesia and sensibility is an irregular line which externally rises 
as high as the point of insertion of the deltoid muscle, and extends several 
inches lower upon the inner and posterior aspect of the arm. Above this 
irregular line of demarcation, about the scapular and clavicular regions, there 
exists great hyperalgesia, the patient complaining that the pain in the 
hand is excited by slight contact, and shouting and swearing from extreme 
agony when the scapula is handled. It is remarkable that bringing the 
scapula forward and holding it in this position gives the sufferer much re- 
lief. As regards the degree of anaesthesia existing below the above specified 
line — i.e., in lower part of arm, entire forearm, and hand, — it may be stated 
that simple contact is not perceived ; that the fracture may be freely handled 
without causing pain ; that pushing pins deeply into the tissues is unnoticed ; 
and that heated objects are not perceived. 

From the patient's assertions about the effects of motion and contact upon 
the neuralgic pain, the belief had grown up that there might exist a relation 
between the symptoms of nerve injury and the fracture of the bones of the 



CASE OF TRA UMATIC BRACHIAL NEURALGIA. 99 

forearm ; in other words, it was feared that the great nerves which pass 
among the muscles of the forearm to supply the hand were caught between 
the fractured bones, or were being compressed or irritated by fragments of 
bone. The question to be decided by the consultants, therefore, was the 
desirability of cutting down upon the fracture and determining whether any 
such pathological state as that above stated really existed. Of course, the 
discovery of the extensive paralysis and anaesthesia above referred to changed 
the aspect of the case materially. It was evident that we had to deal with 
an injury much higher up than the fracture, one producing a complete inter- 
ruption of centripetal and*centrifugal conduction in all the nerve-trunks which 
supply the upper limb. Of course, this being admitted as probable by all 
present, the conclusion was arrived at that no operation on the distal side of 
the injury could relieve the patient of his neuralgia ; said neuralgia being a 
pain referred to the distribution of certain nerves, in accordance with the 
well-known physiological law of reference of sensations, — a pain whose cause 
was a nerve-lesion situated in the axillary space, if not higher. 

Another consultation (Drs. Caro, Sands, Stephen Rogers, and E. C. Seguin) 
was held on August loth, when the question of relieving the suffering of the 
patient was brought up. Dr. Rogers advised, with the view of interrupting 
the neuralgia, complete chloroform anaesthesia for a period of twelve hours. 
Dr. Seguin, considering the neuralgia as dependent upon the irritation of 
central ends of the injured (ruptured) nerves by newly formed (by repair) 
connective tissue, recommended counter-irritation to be applied near the 
supposed scat of nerve lesion, i.e., above and below the clavicle. 

On the 28th of August, Drs. F. H. Hamilton and Seguin were asked by 
Dr. Caro to see the patient. We find him in much the same state, suffering 
more, if possible ; the pain being mainly of a burning character. The pa- 
tient's excitement and irritability are such that details irpon the state of his 
sensations are very difficult to obtain. The wound in the thumb has com- 
pletely healed ; but the fracture exhibits no signs of union. A careful 
examination of the state of sensibility shows that anaesthesia is complete in 
hand, forearm, and lower arm as high as limit indicated above. A new test 
is employed, viz., wire points connected with the maximum secondary 
current of a strong induction apparatus. Patient's general condition has 
somewhat improved. The existence of a severe nerve-lesion high in the 
axillary region (a rupture probably of all the nerves constituting the brachial 
plexus) being unanimously regarded as certain, and the chances of reunion of 
the torn nerve fibres and the regeneration of the peripheral parts of the nerves 
being looked upon as nil, it was proposed by Dr. Hamilton that the arm should 
be amputated near the limit of anaesthesia. It was thought (1st), that through 
the operation, some temporary alleviation of the neuralgia might be obtained; 
and (2d), that the patient would be rid of a member that w T ould ever remain 
palsied and useless, and the care of which would interfere with the taking of 
exercise and with other means of regaining tone and strength. The pro- 
posal was concurred in ; and, on the 29th, Dr. Hamilton dexterously removed 
the arm at about its middle, by the circular method. Very little blood was 
lost, and the operation was well borne. An experiment was made by Dr. Seguin 
upon the amputated arm immediately after its separation. A double-cell 



100 CASE OF TRAUMATIC BRACHIAL NEURALGIA. 

faradic battery was in readiness. The three great nerves, median, ulnar, and 
musculospinal, were rapidly laid bare at the upper part of the separated arm. 
They had lost their normal glistening, opaque appearance, and looked dirty 
and translucent. To these nerves, properly isolated upon glass, both the 
weakest and the strongest possible currents were applied without producing 
the slightest muscular contraction in the arm. The median and ulnar nerves 
were laid bare in the lower third of the forearm, examined in the same man- 
ner, and with the same negative result. Neurility, therefore, was abolished 
in these degenerated nerves, and a positive proof was obtained by this 
experiment of the correctness of the diagnosis of nerve-rupture. Contrarily, 
the muscles in every part of the extremity were found highly excitable, even 
feeble currents producing contractions. The interossei muscles, which respond 
least well, are infiltrated with serum, and are flabby and pale. A hasty 
examination of the arm showed the tendon of extensor carpi radialis torn 
across at its upper part ; no other muscles are injured. Muscles and tendons 
on ulnar side, opposite fracture, are covered with plastic exudations. The 
broken ends of the ulna and radius are not much displaced, but exhibit no 
trace of an attempt at repair. The nerves are in nowise involved in the 
fracture. The articular surface of the elbow-joint has lost some of its polish, 
and appears red. 

One of us again saw the patient at the end of September. ' ' 1 * learned 
that a degree of temporary relief had followed the removal of the limb. 
During the rest of the day of the operation only slight pain was complained 
of, but on the succeeding days it returned with increasing severity, until a 
fortnight later it was as great as ever, perhaps even worse. Patient has now 
completely lost self-control ; he swears frightfully, throws articles of furniture 
about, races up and down stairs in a five-story house, because of the intense 
burning, tearing and shooting pains which are referred to the hand and 
lingers. The worst times are in the afternoon and evening. Patient is then 
in a terrible state of nervous excitement ; he twists and squirms in his bed 
or chair, chews violently upon a handkerchief, and the perspiration pours 
from him. His language is interrupted by groans, oaths, and gnashing of 
teeth. Hypodermic injections of morphia — twenty and forty minims — with 
chloral, temporarily control pain. The appetite and nutrition have remained 
fair. Another consultation is proposed to be held between Drs. Caro, 
Hamilton, and myself. I am prepared to advise the section or resection of 
the nerves which go to form the right brachial plexus, at a point nearest the 
intervertebral foramina. The necessity for the performance of such an 
operation I base upon the diagnosis of injury (rupture) of the brachial plexus 
in the region where it is bound down to the vessels. I intend to cut the 
affected nerves above the seat of injury, and thus cause cessation of 
neuralgia." 

The proposed consultation was never held. It was decided to try the 
controlling influence of a disciplined household upon his mental condition ; 
and he was accordingly sent the next day to the private institution for the 
insane under the charge of Dr. Barstow. The patient, let it be remembered, 

•- Transcript from Dr. Seguin's memoranda. 



CASE OF TRAUMATIC BRACHIAL NEURALGIA. 101 

was absolutely sane ; but it was thought that many of the new surroundings 
into which he would be thrown might strengthen his self-control and will to 
modify his expressions of agony. 

On the 30th of October a brother of the patient called at my office, and 
stated that the family desired to place the patient wdiolly in my care; and he 
inquired what means, if any, remained, which would give a chance of relief 
from his great suffering. The operation above referred to was explained to 
him, and it was agreed that the trial should be made. 

On the 2d of November the patient returned to town, and I visited him the 
same evening. He has changed very much for the better, his color having im- 
proved and his weight increased. He no longer cries out or swears because 
of the pain, but sits in a chair or lies in bed w r rithing, sweating, and chewing 
a handkerchief. The stump is of very good shape, and very nearly well. 
The neuralgia is still terrible, consisting mainly of shooting, tearing pains, 
together with some burning, and a sense of cramp in hand, all pain being 
referred to the extremity .of missing member. Patient has been most judi- 
ciously treated by Dr. Barstow. He has had no morphia or chloroform for a 
month. He has eaten heartily, and has walked about a good deal. 

An examination shows that the stump is sensitive, perhaps more so than is 
normal; the shoulder is much atrophied, and droops; the scapula is rotated 
by the action of the serratus magnus muscle. There exists some tenderness 
over nerves above the clavicle. The pain is continuous, with exacerbations 
in the afternoon, and during bad weather. Besides, he complains of his 
1 ' hand feeling drawn up, " and of ' ' sinews working in the arm. " With excep- 
tion of constipation, no disturbance of any function is present. 

Novemler 5th. — The proposed operation is done by Dr. Sands. Present, 
Drs. Sands, Caro, Geo. A. Peters, Wm. H. Draper, F. K Otis, T. T. Sabine, 
John G. Curtis, McCreery, and E. C. Seguin. Drs. Hamilton and Barstow 
had been invited to attend, but were unable to come. At 10.40 a.m. chloro- 
form Was administered, and anaesthesia continued by means of sulphuric ether. 
An J shaped incision was made, its long arm extending parallel with the 
outer border of the right sterno-mastoid muscle, and its shorter arm following 
the clavicle. The flap was then raised and the connective tissue, with fibres 
of the platysma myoides and clavicular portion of sterno-mastoid muscle, 
divided and turned up. The external jugular vein was turned outward unin- 
jured. Across the exposed triangle a vein larger than the external jugular 
was met with, apparently in very direct connection with the heart (showing 
systolic impulse), and, after being tied with two ligatures, w T as cut across. A 
little deeper the nerves were exposed without difficulty. It should be added 
that the latter steps of this dissection were done without cutting instruments. 
The connective tissue around the nerves did not separate with normal facility; 
the nerves constituting the brachial plexus were much matted together, and 
their dissection was by no means easy; still the first rib w 7 as plainly felt at the 
bottom of the w r ound, the scaleni were visible, and so was the anterior border 
of the right trapezius. The fifth, sixth, and seventh cervical nerves were cut 
in a lump, a piece fully a quarter-inch in length being excised ; the same being- 
done for a thick double cord, which seemed to represent the eighth cervical 
and first dorsal nerves. The pieces removed looked badly, and the nerves felt 



102 CASE OF TRAUMATIC BRACHIAL NEURALGIA. 

more like tendinous cords than like nerves. The surface of section appeared 
yellowish, showed hardly any trace of secondary fasciculi; and the neurilemma 
was unmistakably thickened and injected. More of the nerves (proximal ends) 
were taken away, Dr. Sands carrying his knife as near the scaleni as was 
practicable ; but even there the sections exhibited the appearances of neuritis. 
During the operation no hemorrhage, worth naming, occurred. The carotid 
and subclavian arteries were both felt, but the phrenic nerve was not seem 
Two or three very small arteries and the above-mentioned vein required liga- 
ture. The wound was closed by means of stitches placed . 5 centimeter apart, 
drainage being allowed at the angle of wound. 

This neuritis was not altogether unlooked-for by us. It may prove to be an 
inflammation which has ascended from the injured point, and which may be 
successfully treated afterward. Another possibility is, that the nerves have 
been cut below the seat of injury, in which case the neuralgia will return and 
persist. • 

Patient recovered from anaesthesia with much excitement and delirium ; an 
hypodermic injection of sulphate of morphia .04 and .001 of atropia being 
administered before the ether effects had fairly passed off. After 1 o'clock 
p.m. he slept three hours. At G p.m. he is found rational, and moderately 
exhausted; pulse 120 +, skin moist; has some headache; complains of sore- 
ness about shoulder, and of severe numbness in absent right hand, "just as 
when one's foot is asleep." Is chewing a handkerchief as before operation, 
though this is perhaps from habit. Ordered broths and a draught composed 
of 2. bromide of potassium and 2.6 hydrate of chloral, at 11 p. m. 

9th. — A certain degree of pain returned after operation. Is quieted by hypo- 
dermic injections of morphia, .036, and atropia, .001. Some surgical fever. 

10th. — No change in symptoms; a curious sore has appeared on the left ear. 
It is a superficial dry eschar, about a quarter of an inch square, on outer 
border of helix, on a level with tragus. Is this a reflex nervous nutrition dis- 
order ? Perspires more on right side than left; right brow wet, left quite 
dry. 

26th. — Marked improvement. Numbness, with much burning, still present. 
Has taken KI 2. per diem. Has 1. cc. Magendie's solution of morphia at mid- 
day, 1.20 late at night, under the skin. Wound nearly closed. 

Dec. 10. — Gaining. KI discontinued. Has lately taken quinia sulph. .30 
twice a day; to be continued. Some dozen small blisters have been applied 
to various parts of the stump and shoulder with benefit. Has had exacerba- 
tion in changeable, stormy weather. Cigars have seemed to increase effect of 
morphia injections. 

Jan. 1, 1872. — Last week passed through an attack of pneumonia (left lower 
lobe) ; defervescence in less than 48 hours. Neuralgia still severe, but decreas- 
ing. More self-control. Continue morphia under skin (1.5 to 2.6, in two 
doses), quinia ; and ordered cod-liver oil. 

April 1st. — The issue was closed about the middle of March; since has had 
a succession of blisters applied over stump and chest. Has much improved. 
Now sleeps in daytime and at night; gives much less expression to pain, al- 
though, in bad weather or during a change in the weather, he writhes some- 
what, and perspires. The pain is of same character as at time of last note ; 



CASE OF TRAUMATIC BRACHIAL NEURALGIA. 103 

has much burning ; very rarely any tearing or lancinating pain. Hyperesthesia 
of skin of stump and chest continues. Fingers are still distinctly felt, and 
are the seat of most pain; the median and index appear glued together. Has 
noticed a curious associated sensation; which is. that whenever he squeezes 
strongly with the left hand he feels as if the absent hand were doing the same 
thing. There is much atrophy of muscles about right shoulder. The right 
pupil is smaller than the left;* and he sweats much more on the right than on 
the left side. General health is excellent, weight being 74. kilos. — greater 
than ever before. Receives injections at office, 1.1 to 1.2 (according to 
weather) in the morning (10 a. m.), and .72 to 1. about 7 p. M. 

May 25th. — Since last note has improved in respect to neuralgia. Owing 
to the ^act that he has not taken cod oil for some time, his weight has de- 
creased some twenty pounds. The pain is nearly always burning; very rarely 
is there any shooting pain. The absent fingers ajjpearto be in the same posi- 
tion as that detailed above. During the past three weeks he has observed 
more or less burning pain in cicatrix above clavicle ; this pain is becoming 
daily more noticeable. He has also suffered somewhat from end of the 
stump. Has regularly received hypodermic injections of morphia night and 
morning, 1.1 and 1. of Magendie's solution. An examination of the stump 
and shoulder is made to-day. These parts are very much atrophied, the acro- 
mion and coracoid processes being quite prominent. The scapula has rotated 
outward and upward in such a way that the acromion process is raised, the 
posterior border of the scapula drawn away from the spinous processes of 
the vertebra?, and the inferior angle made to approach the axilla. There is 
no tendency to the "wing 1 ' deformity; i.e., the serratus magnus muscle is 
not paralyzed. This one and the muscles raising the scapula (trapezius and 
levator anguli scapula?) are the only muscles of the region which have escaped 
atrophy. Forced chest-expansion is very good on both sides. There exists a 
lateral spinal curvature in the lower cervical region (convexity toward the in- 
jured side), and another in the opposite direction (compensatory or result of 
pneumonia ?) in the lower dorsal region. The end of the stump is very firm 
and sound ; the cicatrix above the clavicle is also in good condition. State of 
sensibility. — The patient states that he has an extensive surface on the right 
side that is abnormally sensitive. Light contact and pinching are felt a little 
less distinctly on this zone than on the corresponding parts of the left side ; 
the a3sthesiometer test reveals no difference between the two sides. Cold is per- 
ceived a little more distinctly on the left side than on the right. While light 
contact and pinching are less acutely felt in the part touched on the right side, 
these same irritations (and any others) start the neuralgia with a severity 
proportioned to the acuteness of the impression. This falsely hyperaesthetic 
region has the following limits : The entire stump and shoulder; the scapular 
region, and a little of the back inside of and below the scapula ; the axillary 
region, and the pectoral region as low as a point one inch below the nipple ; 
the inner anterior limit is along the right outer edge of the sternum up to the 
supra-sternal notch, where the limit extends quite to the median line, thence 

* This disparity in the state of the pupils was seen very shortly after the opera- 
tion, but no note made of it. 



104 CASE OF TRAUMATIC BRACHIAL NEURALGIA. 

taking an oblique course along the anterior edge of the sterno-mastoid muscle, 
then a little forward so as to include the angle of the jaw and a part of its 
ramus and body; from the lobule of the ear the line extends backward and 
downward to the posterior angle of the scapula. The teeth on the right side 
have been so sensitive that he has not brushed thern for months; nor has been 
able to comb his whiskers on that same side. "We repeat that this abnormal 
sensitiveness is not a true one, not in the parts touched or pinched, but that 
irritation of this zone excites the neuralgic pains, these being of the nature of 
associated sensations. The pupil on the side of the injury and operation is 
distinctly smaller than that on the sound side (left). The perspiration is more 
abundant, and appears more quickly upon the right side than upon the left. 
During the examination the left axilla was moist, but two or three large drops 
of sweat tickled down the side from the right. 

During the last two months the neuralgia has been much less influenced by 
changes in the weather. It is decided to try applications of the actual cau- 
tery to the shoulder and chest. Choice is made of the platinum-tipped cautery 
applied at white heat, and in a superficial way (Brown-Sequard's method). 
Morphia to be continued. 

June 22d. — The cautery was applied in all some five times without produc- 
ing any noticeable relief. Pain is severe, but patient has some hours of sleer), 
and others of comparative ease, while taking only .80 Magendie's solution 
night and morning. Neuralgia presents same character, consisting mainly 
of burning, referred to fingers. These last seem to be in peculiar position 
above described. Patient is left for the summer under the supervision of Dr. 
A. Bray ton Ball. 

December 1st. — Since last note no marked change has occurred. Patient 
still suffers from much burning and from some lancinating. This is, as of 
old, referred to fingers and hand, being felt slightly and seldom in stump or 
supra-clavicular cicatrix. Hallucination regarding position of fingers con- 
tinues the same. He thinks he has had more pain in last two months, but this 
is to be judged in connection with the fact that the morphia has not been 
increased; takes .80 Mag. night and morning. Pupils are still unequal. 
Right side (same parts) still exhibits false hyperalgesia, less marked. Has 
lately combed whiskers and cleaned teeth on that side. Still perspires more 
on right side. Right side of neck and other parts have been irritated, and 
no epileptiform symptoms produced. General health good. 

There are a number of points in this history which, we be- 
lieve, require more extended consideration. 

1. The pathological anatomy of the nerves involved. At the 
time of the amputation, portions of the three great nerves of the 
arm, median, ulnar, and musculo-spiral, were removed within 
two hours after the separation of the limb, and immersed in a 
weak solution of chromic acid. Two or three weeks later, trans- 
verse sections were made of these nerves, and treated in a way 
to be subsequently described 



CASE OF TRAUMATIC BRACHIAL NEURALGIA. 105 

During the operation performed by Dr. Sands, on November 
5th, pieces were removed from the cervical nerves and from the 
dorsal nerve which go to form the brachial plexus. These 
pieces, varying in size from .5 to .75 centimeter in length, 
were cut off as near the scaleni muscles as it was possible to 
carry the knife. As related in the history of the case, these 
fragments and the nerve-trunks from which they were taken 
looked wholly abnormal. The connective tissue surrounding 
them was hardened and thickened, the nervous cords no longer 
appeared pearly white or glistening, and the surfaces of section 
showed no trace of secondary fasciculi and no attempt at break- 
ing up into bundles, as are seen when a normal nerve is cut 
across. These fragments were also immersed in dilute chromic 
acid, and when they were hardened transverse sections were cut 
from them. These sections, and those from the nerve of the 
arm, were stained by neutral carmine solution, the water re- 
moved from them by successive washings in alcohol and abso- 
lute alcohol. They were then made transparent by being floated 
upon oil of cloves, and finally mounted in Canada balsam dis- 
solved in chloroform. 

Before proceeding to the description of the alterations pre- 
sented by these sections, it may be well to give a cursory account 
of the appearance of a normal nerve section prepared by the 
same (Clarke's) method. In section of a normal sciatic nerve* 
seen with a power of 65 diameters (see PL I.), Pig. 1 exhibits 
every nerve fibre as a little circle, within which is a hyaline 
mass, and in the midst of this mass a red dot placed a little to 
one side of the centre in most cases. These parts are the axis 
cylinder as the central dot, the white substance of Schwann or 
myeline as the hyaline mass, and the membrane of Schwann as 
the circle or rounded ovoid. As shown in the figure, these cir- 
cles (varying a little in diameter) crowded together constitute 
the secondary nerve bundles or fasciculi, which are so large that 
most of them are clearly seen by the unaided eye. Between the 
nerve fibres is a uniting substance which appears faintly 
striated ; and here and there are stronger bands of connective 
tissue (trabecule) which are united with the connective tissue 
around the fasciculus. This is shown (b, b', Fig. 1) as a thick 
ring, apparently made up by the aggregation of nearly parallel 

* All spinal nerves present essentially the same appearance. 



106 CASE OF TRAUMATIC BRACHIAL NEURALGIA. 

fibrillse. Around each secondary fasciculus of a spinal nerve 
there is such a sheath appearing as a ring in transverse sections ; 
and these sheaths are united among themselves by more or less 
loose connective tissue (b", Fig. 1). In this loose connective 
tissue run blood-vessels (c, Fig. 1), arteries, and veins of various 
calibre. There are small additional blood-vessels enclosed in 
the perifascicular sheath and in the delicate tissue which sepa- 
rates the nerve fibres. 

a. The changes exhibited by the median, ulnar, and musculo- 
spiral nerves. To the naked eye sections of these nerves show 
traces of.secondary fasciculi, although the picture is far inferior 
to that seen in the normal section. Under a power of 65 diame- 
ters the connective tissue around the nerve and that between 
the secondary fasciculi appears moderately increased in quantity 
and density. The perifascicular sheaths themselves have lost 
their definite outlines, and merge more into the connective tissue 
lying round about them. The sections of blood-vessels seem 
but little changed, and only a few granular (yellow) bodies are 
seen in the interfascicular tissue, mainly in the neighborhood of 
the vessels. The great alteration is in the nerve fibres. In the 
fasciculi very few distinct circles are to be seen, the mass con- 
stituting the fasciculi appearing as a confused design made up 
of fragments of circles heaped one upon the other. In none of 
the remaining circles can an axis cylinder be satisfactorily recog- 
nized. In such circles as exist, the hyaline substance within 
them (myeline) appears more refracting than is usual, and is 
often concentrically striated. We have here the lesions charac- 
teristic of the Wallerian degeneration, i.e., disintegration of the 
nerve fibres, with proportionately little change in the framework 
of the nerves. 

b. The sections from the nerves excised on November 5th. 
These present an altogether different appearance. To the un- 
aided eye they appear like sections of some dense, indistinctly 
fibrillated tissue, tendon for example. Under a low magnifying 
power the general sheath of the nerve is seen very much hyper- 
trophied. The secondary fasciculi vary immensely in size and 
appearance. A few are still rounded, encircled by a distinct 
sheath, and fairly filled with nerve fibres in better or worse 
condition. The majority, however, are broken up into innumer- 
able smaller bundles, the separation being effected by the forma- 
tion of distinct bands of fibrillated connective tissue in the place 



CASE OF TRAUMATIC BRACHIAL NEURALGIA. 107 

of the scanty network described as lying between the fibres in 
a normal section. Between many of these fragmented fasciculi 
are huge masses of waving, dense connective tissue, with abnor- 
mally large vessels, and with a great quantity of granular 
pigment deposit. This yellowish pigment lies principally im- 
mediately around the blood-vessels, or in the connective tissue 
near them. 

As regards the nerves themselves, it may be stated in general 
terms that they are in a state of atrophy. In one fasciculus, for 
example, there are very few fibres which present the circular 
outline, hyaline mass, and central dot characteristic of the 
normal fibre seen in transverse section. The vast majority are 
much smaller than usual (appearing of about the same dimen- 
sion with 300 diameters as normal fibres do with 65) ; they vary 
immensely in diameter, and many are represented only by parts 
of small circles. No masses of embryonic cells are seen in any 
part of the preparations. Fig. 3 is drawn from a preparation 
made from the eighth cervical and first dorsal nerves under a 
power of 300 diameters, and exhibits very fairly the condition 
existing in one of the best preserved parts of the section. One 
large fasciculus is quite entire, though the majority of fibres 
composing it are shrunken and empty. Above this fasciculus 
are very heavy masses of connective tissue, which is closely 
connected with the perifascicular sheaths. To the left of this fas- 
ciculus is seen a blood-vessel having round about it much yellow 
granular pigment. The fasciculus represented in the left upper 
part of the sketch is broken up by increase of the connective 
tissue into tertiary fasciculi, and many smaller aggregations of 
atrophied nerve fibres ; in some places single fibres are seen 
surrounded by dense connective tissue. In other parts of the 
preparation more extreme changes are to be seen, in some fas- 
ciculi nearly every fibre being separated from its neighbors by 
newly formed fibrillar substance. 

To resume : The nerves in the upper cervical region present 
the lesions characteristic of chronic neuritis, viz., much increase 
and condensation of the framework, with comparatively miner 
change in the nerve fibres. In other words, the pathological 
process in these nerves has been primarily hyperplastic, and the 
neural atrophy secondary and incomplete ; whereas, in the nerves 
removed from below the axillary space, the neural atrophy was 
complete and primary, the changes in the framework very slight. 



108 CASE OF TRAUMATIC BRACHIAL NEURALGIA. 

In the one case we have the lesions of chronic hyperplastic 
neuritis ; in the other, those of the Wallerian degeneration. 

2. Nature and seat of the injury to the nerves. 

The absolute anaesthesia of nearly the whole arm exhibited by 
the patient previous to its removal, and which probably existed 
immediately after the infliction of the injury, points to a com- 
plete solution of continuity in all the nerves which supply tho 
lower arm, forearm, and hand with sensory filaments.* Further, 
the patient had complete paralysis of muscles situated far above 
the limit of anaesthesia, those which act upon the upper part of 
the humerus and some of those moving the scapula. The dis- 
tribution of motor palsy and of anaesthesia in this case fully 
illustrated van cler Kolk's law of distribution of sensory and 
motor filaments of one nerve trunk, viz., that the former are sent 
to parts which are moved by muscles innervated by the latter, t 
We therefore had ample clinical reasons for localizing the injury 
at least as high as those parts of the brachial plexus which lie 
behind and just above the clavicle, and also for considering that 
the injury consisted in a complete disruption of the nerve trunks. 
Another possibility presented itself to our minds, viz., the tear- 
ing out of the roots of the nerves which constitute the brachial 
plexus from their attachment to the anterior and posterior as- 
pects of the spinal cord. Such an accident has been placed on 
record by Flaubert,:): occurring as a consequence of forced exten- 
sion made to reduce an old dislocation ; but in this case the patient 
died in a few days with symptoms of inflammation of the spinal 
cord, corroborated by the autopsy. Guided by the result of this 
case, and by the fact that our patient had at no time presented 
any symptom of spinal meningitis or myelitis, we felt reasonably 
certain that the nerve roots in this case had not been torn out. 
Having thus excluded intra-spinal rupture and determined with 
certainty the lowest possible limit of the injury, the question 
arose, whether we could arrive at a still more exact knowledge 
of the seat of nerve rupture ; where in this tract between the in- 
tervertebral foramina giving issue to the fifth, sixth, seventh, 
eighth cervical, and to the first dorsal nerves, and the upper 

■" Compare Mitchell, Injuries of Nerves. Philadelphia, 1872; p. 227. 

f Schroeder van der Kolk. On the Minute Structure and Functions of the 
Spinal Cord and Medulla Oblongata. Translated by the New Sydenham Society. 
Vol. iv., 1853 ; pp. 8, 9. 

% Repertoire General d' Anatomic et de Physiologie Pathologique. Vol. iii., p. 
55. Cited by Lo Bret, Mem. de la Soc. de Biologie, 1853, p. 121. 



CASE OF TRAUMATIC BRACHIAL NEURALGIA. 109 

limit of the axillary space, was the laceration most likely to have 
taken place ? It appeared to us impossible to make a satisfac- 
tory answer to this question. The microscopical examination 
of the nerves corroborated the diagnosis reached upon clinical 
grounds, since the sections taken from the upper part of the 
cervical nerves showed neuritis, while those cut from nerves be- 
low the axilla exhibited the changes of descending or Wallerian 
degeneration. It is therefore right to conclude that the excision 
has been made, as intended, above the seat of laceration. 

In this connection it may not be amiss to recall the exact 
mechanism of the accident. The patient's right hand was firmly 
clasping the rammer, and all the muscles of the arm were in 
activity during the effort of ramming home the charge. The ex- 
plosion naturally drove the hand forward and outward with 
incredible violence, the arm following the same direction, and 
being for the moment in a state of extremely violent extension. 
So enormous was the strain upon this limb that the patient was 
thrown bodily quite a distance. We see no reason for not admit- 
ting that the fracture of the bones of the forearm occurred at the 
beginning of this movement of extension. This being granted, 
it follows that a great strain was put upon the soft parts which 
still connected the lower part of the forearm with the upper, and 
that the blood-vessels and nerves were greatly elongated. Dur- 
ing this elongation the nerves gave way at their weakest point, 
i.€., where they are most firmly bound down, and where they 
interlace and anastomose — behind the clavicle. 

Besides Flaubert's case above referred to, we have met with 
quite a number of instances of obscure nerve injury caused by 
the reduction of old shoulder dislocations, but the details given 
are so meagre as to make the cases quite useless. An exception 
to this statement is the case recorded by Le Bret.* A young 
soldier, who had dislocated his right shoulder, underwent the 
operation of reduction on the same day. The traction was done 
by men pulling upon a sheet firmly tied around the arm just 
above the elbow. Immediately after the reduction, without any 
special pain having been felt, the patient noticed that his arm 
and forearm were paralyzed. "When seen by Le Bret, five months 
later, there existed complete anaesthesia below the bend of the 
elbow, besides palsy of the arm. The corresponding side of the 
neck had lost motion, and was anaesthetic ; the right upper eye- 

* Meinoires de la Soc. de Biologie do Paris, 1853, p. 119. 



110 CASE OF TRAUMATIC BRACHIAL NEURALGIA. 

lid covered the globe, and vision was impaired ; the right iris 
was slightly contracted. There were some lancinating pains in 
fingers and arm. The nerves (inner aspect of arm, and above 
clavicle) were tender to pressure. Some improvement took place 
in motion of arm and neck, and the ptosis was cured. The 
author believes that the nerves were torn across in the region of 
the brachial plexus. 

3. The demonstration of persistent muscular irritability at 
a considerable period after the muscles had ceased receiving 
nervous influence. 

The arm was removed eight weeks after the reception of the 
injury, and, as related above, while no muscular contractions 
could be obtained by faradizing the nervous trunks at various 
points, almost normal movements were produced by the direct 
application of the current to the muscles themselves, even those 
(inter ossei) which had apparently suffered much in their nutri- 
tion. The bearing of this experiment upon the question of the 
independence of muscular irritability might detain us awhile, 
were it not that this paper has already reached a considerable 
length. Let it suffice to state that this result agrees with that 
obtained in the inferior animals. The fact that functional capac- 
ity survives in muscles for a period six or twelve times longer * 
than in nerves, in cases where those organs have been cut off 
from communication with the spinal cord, has been demonstrated 
by a great number of physiologists. Among the earlier of these 
we may name Marshall Hall, J. Muller, Giinther and Schon ; 
the latter fixing the date of loss of excitability in nerve trunks 
at eight days after section. Later experiments by Longet, Schiff, 
Landry, Vulpian, and many others have resulted in positively 
limiting the time at four days. On the other hand, these ob- 
servers agree in stating that muscles retain for a much longer 
period the power of reacting under immediate stimuli. Some of 
Longet's t conclusions on this point are worth reproducing : 

" 1. In mammals, a motor nerve, when separated from the cer- 
ebrospinal axis, loses all excitability after the fourth day. At 
that time the application of mechanical, chemical, and electrical 



* Dr. Brown-Sequard asserts that there is sometimes no diminution of muscu- 
lar irritability : he has found it as great as in the normal state nineteen months 
after the whole central end of the facial nerve has been drawn out from its exit at 
the stylo-mastoid foramen. Bulletin de la Societc Philomathique, 1847, p. 83. . .. 

f Traite dc Physiologic, t. ii. p. 619. Paris, 1869. 



CASE OF TRAUMATIC BRACHIAL NEURALGIA. Ill 

irritants to any part of the distal end of the nerves is followed 
by no muscular contraction. 

" 2. Contrarily, a muscle whose motor nerve is no longer 
excitable, will, even after the lapse of twelve or more weeks, 
respond perfectly to any direct stimulus." 

Landry,* however, states that in the human species, muscular 
irritability under these circumstances is abolished in the seventh 
week. The almost perfect response of the muscles to stimuli in 
our case, and their apparently normal structure at the end of 
eight weeks, completely overthrows Landry's conclusion. The 
causes of error in the author's observations lay, 1st, in the fact 
that he was unable to apply the electric current directly to the 
muscles, although he made use of electro-puncture ; and that, 
2d, in all likelihood there existed in his cases more or less active 
impairment of nutrition in the paralyzed muscles, owing to irri- 
tation of the nerves at their origin. 

Yulpiant rightly insists upon the value of the fact observed 
by him in animals, that muscles deprived of innervation which 
do not contract when the electric (faradic?) current is made to 
pass through the moistened skin, do so fairly when the electrodes 
are placed immediately upon the muscular substance ; and he 
goes on to throw doubt upon the observations made by clini- 
cians in regard to the early (fourth — eighth day's) loss of electro- 
muscular contractility in certain palsies — the "rheumatic" pa- 
ralysis of the face, for example. It is to be regretted that in 
our case tlje patient's great suffering deterred us from faradizing 
the muscles of the arm before its amputation.^ As it stands, 
our observation is in favor of a prolongation of muscular irrita- 
bility in man after nerve section for a period quite as long as 
that determined in the lower animals. 

4 Some of the symptoms appear to us especially interesting. 

(a) In the first place, there are signs pointing to a paresis of 
the vaso-motor nerves on one side of the face, neck, and chest. 
The right pupil was noted as smaller than the left immediately 
after the operation, and from an early period the patient per. 
spired much more upon the right side than the left. Besides, 
there was a peculiar condition of sensibility on a large extent of 

* Traite complet des Paralysies, t. i. pp. 40-41. Paris, 1859. 
f Lecons sur la Physiologie du Systeme Nerveux, p. 245. Paris, 1866. 
% Through causes beyond our control, the galvanic current could not be applied 
to the nerves and muscles in the above-detailed experiment. 



112 CASE OF TRAUMATIC BRACHIAL NEURALGIA. 

the right side of the body. At one period this is spoken of as 
hyperalgesia ; but a later examination showed that there was no 
abnormal tenderness in the part touched, and that the pain pro- 
duced by contact was felt in the absent arm and hand. Still, it 
should be borne in mind that the patient's self-control and esti- 
mation of the nature of his sensations were not always normal,' 
so that it cannot be asserted that there did not exist, at an early 
period, true hyperalgesia. The sesthesiorueter certainly taught 
us nothing. The extensiye surface, falsely sensitive, bore the 
same relation to the brachialgia that many " tender points " 
do to ordinary neuralgia. An impression transmitted to the 
spinal cord, at a point near the portion which gives origin to the 
nerves supplying the region affected with neuralgia, causes action 
of the sensory tract connected with these nerves, and conse- 
quently produces a referred sensation of pain. One of us * had 
occasion to observe a curious example of this associated painful 
sensation in his own person, last summer. A lower incisor tooth 
had become the seat of tartar deposit, and the gum below was 
shrunken, red, and tender to the brush. There had never been 
toothache. One day a small pimple appeared on a level with 
the upper margin of the thyroid cartilage on the snme (right) side 
as the unhealthy gum ; and during the entire period of growth 
and maturity of the pimple, pressure (even light) upon it pro- 
duced an acute pain in the gum around the above-mentioned 
tooth. The experiment was repeated scores of times ; and it' 
was further observed that touching the gum did no # t produce 
pain in the pimple. Here an impression made upon a branch 
of the superficial cervical plexus, transmitted to the sensory tract 
of the upper cervical cord and medulla oblongata, excited in the 
latter action of the cells connected with the third branch of the 
trigeminus. 

(b) The disturbance of nutrition, which produced a slough 
upon the left helix, is difficult of explanation. It is well to re- 
member in this connection that Brown-bequard produces gan- 
grene of the edges of the external ear, at will, in guinea-pigs, by 
injuring the medulla oblongata. 

(c) The burning pain (causalgia of Mitchell) did not appear 
immediately after the injury ; this being in accordance with the 
rule laid down t by the distinguished author just named. As 

* Dr. Seguin. 

f Mitchell. Injuries of Nerves, and their Consequences, p. 197. Philadelphia, 
1872. 



CASE OF TRAUMATIC BRACHIAL NEURALGIA. 113 

regards the date of the appearance of this peculiar pain, we can 
obtain no definite information. 

The expressions of agony, in action and words, employed by 
our patient corresponded singularly with those recorded by Dr. 
Mitchell in his works upon nerve injury. * 

With reference to the extraordinary severity and persistence 
of burning pain in cases of injury to nerves, we would recall the 
fact, first distinctly stated by Cruveilhier,t that loss of the power 
of perceiving thermal impressions occurs later than the loss of 
various other varieties of sensibility, and indicates absolute 
anaesthesia ; and we suggest that inasmuch as the thermal sense 
is the last to disappear in gradual diminution of sensibility, so 
in a neuralgia caused by irritation of nerve trunks, this most 
deeply rooted, or most fundamental mode of sensation is most 
affected, and burning is felt acutely when common pain and for- 
mication have almost or quite ceased. It is well' known that 
extreme irritation of the skin, after producing ordinary pain, 
causes intense burning ; an event frequently met with in surgi- 
cal practice ; and, moreover, the contact of extremely cold 
bodies with the skin sets up a painful sense of heat. 

5. The operation above described is believed to be the only 
on'e of its kind ever attempted. Excision or division of the 
spinal nerves has generally been performed on the smaller 
branches ; and, excepting the case herewith related, has never 
involved the primary trunks near their points of exit from the 
spinal canal. Neurotomy, when undertaken for neuralgia of 
traumatic origin, has, in a great many instances, effected a per- 
manent cure, and in these cases is far more likely to prove suc- 
cessful than when it is performed for the idiopathic forms of the 
disease. If the nerve tissue is healthy at the point of section, 
the operation can hardly fail ; yet success has followed the 
operation in not a few cases where the divided nerve was thick- 
ened and inflamed. In the' lower extremity, excision of the 
smaller nerves has repeatedly been performed, and in several 
instances, the great sciatic has been either excised or divided. 
Dr. Mitchell % reports a case in which Dr. Nott excised 3. cen- 
timeters of the great sciatic nerve, close to its point of exit 

* Compare, also, Mitchell, Morehouse, and Keen. Gun-Shot Wounds and other 
Injuries of Nerves. Philadelphia, 1864. 
f Anatomie Pathologique, liv. xxxviii. p. 9. 
X S. Weir 'Mitchell, op. cit. pp. 285, 286. 
8 



114 CASE OF TRAUMATIC BRACHIAL NEURALGIA. 

from the pelvis, for traumatic neuralgia caused by a gunshot 
wound of the leg. Amputation of the leg, reamputation of the 
stump, excision of the sciatic nerve in the popliteal space, and 
amputation of the thigh, had already been performed in succes- 
sion without avail. Partial relief is stated to have followed the 
final operation performed by Dr. Nott. 

Other cases of division of the great sciatic nerve are recorded 
by Malagodi, Mayor, Nelaton, and Jobert de Lamballe. In Jo- 
bert's case the operation was performed for sciatica. Pain 
ceased at once ; but death occurred six months subsequently from 
paralysis and bed sore. 

In the upper extremity, excision of the median and several 
other branches of the brachial plexus has often been practiced, 
and with various results." In some cases the operation has 
effected a complete and permanent cure ; while in others it has 
afforded no ' benefit. Several years ago one of the authors f 
treated a patient in Bellevue Hospital who suffered from violent 
neuralgia and chorea, caused apparently by a neuroma which had 
formed upon the face of a stump after amputation of the arm 
near a shoulder joint. The neuroma was laid bare by dissection 
and was found to be connected with all the descending cords of 
the brachial, excepting the circumflex. These were pulled down- 
ward, and, together with the auxiliary vessels, divided at about 
an inch above their seat of attachment to the neuromatous swell- 
ing. The neuralgia was relieved by the operation while the 
patient remained under observation, but the choreic symptoms 
persisted. He left the hospital about two months after the 
operation. 

In the case which forms the subject of this article, the opera- 
tion of excision of the spinal nerves was undertaken partly as a 
last resort, and partly because it was thought that the danger 
of performing it would be considerably reduced, in consequence 
of the previous removal of the arm by amputation. It is inter- 
esting to observe, however, that no serious nutritional changes, 
except those affecting the muscles, took place in the parts sup- 
plied by the divided nerve trunks. 

Another point of interest is the practicability of the operation 
when considered merely with reference to the difficulty and 

* Schmidt's Jahrbucher, cxxii. p. 218 ; Bd. cxiii. p. 298 et s^q. 
f Dr. Sands. 



CASE OF TRAUMATIC BRACHIAL NEURALGIA. 115 

danger attending its execution. Under ordinary circumstances, 
supposing the nerves to be healthy near the points of section, 
the operation would cause no embarrassment to a skilful sur- 
geon, and all the cords of the plexus might be exposed and di- 
vided without dangerous interference with the neighboring blood- 
vessels. But, even in the present case, where the nerve trunks 
were pretty firmly adherent to the surrounding tissues, their 
isolation was satisfactorily accomplished by careful dissection ; 
and the wound made by the operation healed readily, without 
profuse suppuration. 

Examination of the nerves excised led to the unsatisfactory 
conclusion that they were diseased above the line of section ; 
and it is not easy to understand, on anatomical grounds, why any 
benefit should have followed the operation. The nerve trunks, 
however, were divided pretty close to the intervertebral fora- 
mina ; and, if it be assumed that the cause of pain resided in 
their proximal ends, it is not improbable that the tension of the 
latter may have been diminished, and their relations otherwise 
favorably altered as a consequence of the handling to which 
they were subjected previously to their division. Such an ex- 
planation seems plausible from the results that attended an 
operation recently performed by Professor von Nussbaum, an 
abstract of whose paper appears in the present number of this 
journal. It may also be supposed that the cutting off of a con- 
siderable portion of irritated nerve trunk from communica- 
tion with the spinal cord diminished the neuralgia by reduc- 
ing the total amount of irritation transmitted to the nervous 
centre. 

We may sum up the case by stating that a neuralgia of a class 
known to resist all ordinary treatment was much relieved by an 
operation not dangerous in itself. We did not obtain radical 
success, because we failed to find healthy nerve trunks at the 
place of section. The diagnosis of the seat of injury was correct 
enough, but the ascending neuritis baffled us. 

We are indebted to Dr. Caro for a statement of the case as it 
appeared to him, but as his letter contains nothing that is not 
recorded in the above history, we take the liberty of omitting 
it. 



116 CASE OF TRAUMATIC BRACHIAL NEURALGIA. 

EXPLANATION OF PLATE I. 

Fig. 1. Transverse section of fasciculus of normal spinal nerve. 

a, Xerve fibres seen in section, exhibiting circle (membrane of Schwann), hyaline contents 
(myeline), central dot (axis cylinder). 
b', Sheaths of secondary fasciculi. 

I', Trabecular of connective tissue which subdivide fasciculi. 
b", Interfascicular connective tissue. 
c, Sections of blood-vessels. 

Fig. 2. Fasciculus from ulnar nerve, in middle of aim, showing the lesions of Wallerian degen- 
eration. 

«, Confused outlines of nerve fibres, caused "by loss of myeline and axis cylinder, and collapse 
of membrane of Schwann. Xot one axis cylinder is to be seen. 

b and b', Sheath of fasciculus, and interfascicular areolar tissue, a little thickened. 

c, Unaltered, blood-vessel. 

Fig. 3. Section from lower cord of brachial plexus near intervertebral foramina, showing the 
lesions of chronic neuritis. 

a, Secondary fasciculi, showing atrophied fibres (circles not much larger, under three hundred 
diameters, than those of normal nerve under sixty-five diameters) ; very few axis cylinders present. 
Tissue between fibres increased. 

a', Small aggregations of fibres, separated from others by dense inter-fibrillar connective tissue. 

b, Immensely hypertrophicd interfascicular areolar tissue. Sheaths of fasciculi no longer dis- 
tinct. 

c , Dilated blood-vessels surrounded by altered connective tissue. 

d, Yellow granular pigment lying in areolar tissue, mostly in neighborhood of vessels. 

The various specimens were prepared according to Clarke's method. 



CASE OF TRAUMATIC BRACHIAL NEURALGIA. 117 




ON THE INHIBITOKY AEKEST OF THE ACT OF 
SNEEZING, AND ITS THEEAPEUTICAL APPLICA- 
TIONS.* 

In the early summer of 1869 I discovered that sneezing could 
be arrested or prevented by forcibly rubbing the skin below and 
to either side of the nose. I at once communicated this fact to 
the editor of this Journal, and in my letter pointed out the 
inhibitory nature of the phenomenon ; classing it with the arrest 
of the heart's action in Weber's experiments and with the arrest 
of spinal epilepsy by irritation of the great toe. J I was soon 
made aware that this simple means of stopping sternutation was 
known to many outside the profession, and that it had been 
formally recommended by Diday§ in 1843. More recent re- 
searches have shown me that Haller |j (perhaps Bartholinus 
before him 1), and Marshall Hall ** had called attention to the 
possibility of arresting sneezing by irritating the skin between 
the nose and the angle of the eye (Haller), or by rubbing the 
end of the nose (M. Hall). 

I venture to treat formally of this small matter, because I was 
perhaps the first to call attention to the correct explanation of 
the arrest, and because I have long had in mind certain thera- 
peutical applications of this method. Before proceeding to state 
the circumstances which may indicate the arrest of sneezing, a 
few words about physiological and pathological sternutation may 
not be out of place. 

1st. What is the physiology of sneezing? A most distin- 

i __ 

* From|he Archives of Scientific and Practical Medicine, March, 1873. 

f See Brown-Sequard, Archives of Scientific and Practical Medicine, No. 1, 
Jan., 1873, p. 89. 

X Brown-Sequard, Archives de phys. normale et pathologiqne, i. p. 157, 1868. 

§ Diday, Xote snr un moyen simple de prevenir on d'arreter la toux dans 
certaines maladies. Gazette Med. de Paris, 1843, pp. 103-106. 

I Haller, Elementa physiologic, t. iii. p. 304. Lausanae, 1766. 

IT Th. Bartholinus, cited by Haller in op. cit: (passage not found in B.'s works). 

* - Marshall Hall, Diseases and Derangements of the Xervous System, p. 99. 
Lond., 1841. 



INHIBITORY ARREST OF SNEEZING. 119 

guished physiologist * lias said that " sneezing is a sudden and 
violent contraction of the expiratory muscles consequent upon 
the closure of the upper part of the air passages. * * * The 
diaphragm, contrarily to what is taught by many ancient and 
modern writers, takes no part in the act of sneezing ; it is not an 
expiratory muscle, and acts only in the deep inspiration which 
precedes sneezing." Austin Flint, jr.f defines sneezing as " a 
convulsive action of the expiratory muscles succeeding a deep 
inspiration ; the air being violently expelled, with a characteristic 
sound, through the nares." Carpenter % states that the act of 
sneezing is accomplished by a violent expiratory effort. Haller § 
speaks of sternutation as consisting of a spasm of the diaphragm 
in the first place, causing a deep inspiration, this being followed 
by spasmodic action of the muscles of expiration. Morgagni || 
also considers the act of sneezing as caused principally, if not 
wholly, by spasmodic action of the diaphragm. Many writers 
mention the associated movements of the face, head, neck and 
limbs, which every one must have observed in his own person 
while sneezing. After the deep inspiration, the air is held in 
the chest by closure of the glottis, then escapes principally 
through the nose, the isthmus of the fauces being closed. This 
is the typical sneeze ; but custom has brought about the discharge 
of a part of the air through the mouth, in order to prevent the 
very result fcft* which the act of sneezing seems fitted, viz., the 
expulsion of mucus from the nostrils. I desire particularly to 
call attention to the Hallerian view of the physiology of the act. 
It appears to me that the deep inspiration which w T e take previous 
to sneezing is really spasmodic, and due to a morbid (unusual) 
irritation of the centre of origin of the phrenic nerves. In sup- 
port of this ancient view we have the fact that in cases of 
excessively prolonged sneezing (Brown-Sequard's and Mosler's 
cases) the pain complained of is located in the neighborhood of 
the diaphragmatic insertion. Could we prevent this first or 
preliminary act, we should always be able, it strikes me, to avoid 
sneezing. 



* J. Muller, Manuel de physiologie (ed. Littre), t. i. p. 278 . Paris, 1851. 
f The Physiology of Man, yoI. i. p. 395. New York, 1866. 
X Principles of Human Physiology, p. 333. Seventh edition. Lond., 1869. 
§ Albertus Haller, Elementa physiologiae, loco eit. 

| Morgagni, De sedibus et causismorb. English ed., by Benjamin Alexander, 
M.D. Vol. i. p. 341, Letter XIV. art. 26, 27. London, 1769. 



120 INHIBITORY ARREST OF SNEEZING. 

The cause of physiological sneezing usually consists in an 
irritation of the nasal branches of the trifacial nerve by conges- 
tion, dust, odors, mechanical or chemical contacts. In many 
persons the spasm is easily brought about by the action of light 
upon the conjunctivae (optic nerve also ?). It has been stated 
that the application of a spirituous liquor to the anterior part 
of the palate may act as an excitant. * I have been informed by 
a well-known medical man that, when a boy at college, he was 
in the habit of exciting sneezing in his own person by scratching 
a certain spot upon his head, near the vertex, and a little to one 
side of the median line ; thereby causing frequent disturbances 
in the class-room. Sneezing is spoken of by older writers as 
preceding attacks of epilepsy, t and one author % states that it is 
very commonly observed just before sexual congress. Romberg § 
states that one of the listeners to his lectures had informed him 
that he was obliged to sneeze whenever a salacious thought 
suggested itself to his mind. 

2d. Under what circumstances can sneezing itself merit the 
name of a disease ; when does the act become pathological ? The 
older writers on medicine appear to have had their attention 
directed to this matter. Sauvages,|| who recognizes six varieties 
of sternutation, says that epidemic sternutation had before his 
day proved so violent as to cause death. He does not give any 
reference to his authority for this statement, and I have been at 
some trouble to trace the report, and have found it attributed 
to an author named Polydorus Yirgilius,^ whose work I have 
been unable to. procure. Morgagni,** Bonetus,tt Albrecht^t 
Fabricius Hildanus,§§ and Lancisi,||| are quoted as reciting fatal 
cases. Morgagni's case is a good one ; an autopsy yielding 
negative results having been made. Bonetus does not speak 

* De Lens, cited by Rullier, Diet, des sciences medicales, t. lii. p. 578, 1821. 

f Stalpart van der Wiel, Obs. rarior. med. — anat.-cb.ir. Lugd., Batav., 1687. 

% Amatus Lusitanus, cited by van der Wiel, op. cit. 

§ Romberg, Nervous Diseases of Man, vol. i. p. 349, Syd. Soc. Trans. Lond., 
1853. 

I Sauvages, Nosologie medicale, t. ii. pp. 50, 52. Paris, 1771. 
TT Polydorus Virgilius, de invent, rerum. Lib. 6, cap. 2. 
** Morgagni, op. cit. Letter XIV. art. 27. 

ff Bonetus, Sepulchretum anat. vol. i. lib. 1. sect. xx. obs. xvii. Geneva?, 1700. 
449. 

XX Albrecht, in Ephern. naturae curios. Dec. II. obs. xii. p. 38, 1687. 
§§ Fabricius Hildanus. Opera omnia, 1646. Cont. I. obs. 24, p. 26. 
Q|| Lancisi, De subitaneis mortibus, p. 45. Romse, 1709. 



INHIBITORY ARREST OF SNEEZING. 121 

from personal experience, but relies on the statement of a sup- 
posed eye-witness, Famianus Strada ; the subject sneezed twenty- 
four times, and expired during the twenty-fifth sternutation, it 
is supposed, from rupture of the vessels of the brain. Albrecht's 
case is circumstantially related, and maybe accepted. On read- 
ing Lancisi's work I found that he referred to the same case as 
Bonetus. We are, therefore, willing to admit the existence of 
only three fatal cases, one of these being imperfectly recorded. 
Hildanus's work I have not been able to consult. Haller* 
observed a case in which a deviation upward of the eyeball was 
produced by violent sneezing. Erasmus Darwin t places ster- 
nutation in his Class II. (diseases of sensation), Orclo I. (increased 
sensation), and Genus I. (increased action of the muscles) ; to- 
gether with diseases which he considers allied species, such as 
asthma, singultus, tenesmus, parturition (!) etc. Romberg % re- 
cords an instance of sneezing extending over a period of four 
years ; and the case of a woman who was seized with violent 
sternutation whenever conception occurred — the fit of sneezing 
usually taking place in the morning. Sir Benjamin Broclie§ saw 
two cases of very severe and prolonged sneezing, in both of 
which profuse secretion of serous fluid took place from the nos- 
trils. Among recent writers upon diseases of the nervous sys- 
tem Handfield Jonesil and Eulenberg^f have considered the subject 
in a systematic way, and the former author has advanced the 
view that sternutation may sometimes be due to a central cause. 
Dr. Peter Young** communicated a case of prolonged sneezing 
to the Obstetrical Society of Edinburgh, occurring during the 
middle term of pregnancy, and ultimately causing abortion. On 
becoming pregnant a second time the woman experienced similar 
fits of sneezing, beginning, as before, about the fourth month of 
gestation. A remarkable case has been described by Mosler,tt 
as occurring in a young girl. The patient, previously rendered 

- Haller. op. cit. 

f Darwin, Zoonomia, vol. ii. p. 222, Am. ed. Phil., 1797. 

% Loco cit. 

§ Works, Vol. iii. p. 173. London, I860. 

I C. Handfield Jones. Studies on Functional Nervous Disorders, pp. 644-46. 
Lond., 1870. 2nd ed. 

\ A. Eulenberg. Lehrbuch der functionellen Nervenkrankheiten, pp. 672, 3. 
Berlin, 1871. 

** Proceedings of Edinburgh Obstetrical Soc. in Edinb. Medical Journal. Nov., 
1861, p. 492. 

ft Mosler, Virchow's Archiv. Bd. xiv. s. 557, 565. 1858. 



122 INHIBITORY ARREST OF SNEEZING. 

anaemic by various causes, became affected with an acute inflam- 
mation of the meatus and deeper parts of the ear, and shortly 
afterward began to sneeze in very different paroxysms. The 
frequently recurring spasm was very violent, and soon reduced 
the patient to a state of alarming prostration. For three days 
she was able to take but very little food, and obtained no rest ; 
she became aphonic, the sides of the thorax corresponding with 
the diaphragmatic insertion became the seat of extreme pain, 
the pulse attained a rate of more than 120 beats per minute, the 
face was flushed, and the nasal and buccal mucous membranes 
dry. The ear was swollen and tender, and there existed much 
pain in the whole of the same side of the face. A warm bath, 
together with cold affusion to the head and spine, and two doses 
of .01 morphia put an end to the threatening disorder, after it 
had continued eighty hours, and after the patient had sneezed 
at the least estimate fifty thousand times. A severe case of 
sneezing lasting over a week, and accompanying a first menstrual 
period, is reported by Dr. Trautmann, Sr." Cases of severe 
sneezing are also recorded by many of the older authors, among 
whom may be named Delius,t Lanzoni,^ Schubart,§ the two 
Franks.il In the case of Delius the sternutation was allied with 
hiccough in the course of a malignant fever. Finally Dr. Brown- 
Sequard has told me of a case observed by him in which violent 
sneezing occurred during the progress of an inflammatory affec- 
tion of one-half of the medulla oblongata, diagnosed during life, 
and verified by a post-mortem examination. In this patient, the 
pain caused by the spasm was about the base of the thorax, on 
both sides. 

The causes of pathological sneezing may be classified into , 
local (nasal), central, and peripheral. The local cause may be 
an inflammation of the mucous membrane of the nose, vibriones 
irritating the mucous membrane (in hay-fever, Helmholtz T), 
the presence of a foreign body in the nostrils (snuff, various 



* Schmidt's Jahrb. Bd. viii. p. 50, from Sumraarium, Bd. x. Hfl. 3, p. 378. 

f Delius, in Acta Phys. — Med. Acad. Cagsareae-Leopold-Carol. Vol. viii. cbs. 
cviii. p. 380, 1748. 

% Lanzoni, in idem. Vol. i. obs. lxiii. p. 117, 1727. 

§ Schubart, in Ephem. naturae curios. Dec. I. obs. cxxxviii. p. 211, 1672. 

|| J. Frank, Praxeos medicas universae precepta. Vol. ii. p. 831. Cited by 
Komberg, op. cit. 

Tf Cited by Eulenberg, op. cit. p. 672. 



INHIBITORY ARREST OF SNEEZING. 123 

other sternutatories, the larva? of insects," etc.). Concerning 
the causes of sneezing produced by morbid states of the nervous 
centres, we really know nothing. Perhaps many of the hysteri- 
cal cases may be due to this cause. The causes acting from a 
distance are numerous. Uterine, t intestinal^ pulmonary 
(asthma and whooping-cough), conjunctival or retinal irritation 
may produce the spasm. 

In one of Romberg's cases § the third branch of the trigemi- 
nus was found diseased before its exit from the skull. In Mos- 
lems || extraordinary case, inflammation of the ear, causing irri- 
tation of branches of the trigeminus, was undoubtedly the cause 
of the spasm. Mosler attempted to produce sneezing in dogs 
by direct irritation of the auricular filaments of the fifth pair, 
but without success. 

Treatment the most varied and extraordinary has been tried 
for the relief of morbid sneezing. Bartholinus, quoted by Haller, 
seems to have been the first to suggest irritation of a sensitive 
nerve of the face, between the angle of the eye and the nose, as 
a means of arresting the spasm. Haller speaks of the plan as if 
he had tried it himself. Morbid sternutation has been cured by 
the use of snuff, 1 and Darwin f* asserts that, " when it is ex- 
erted to excess it may be cured by snuffing starch up the nos- 
trils." Dr. Gairdnerft strongly advocated the use of blisters to 
the nape of the neck, not only for the arrest of the spasm under 
consideration, but also for the cure of convulsive cough and 
hiccough. This means is perfectly analogous to that proposed 
by Bartholinus, Haller, Diday, and the author : an irritation 
varying in intensity being transmitted to the centres in the 
spinal axis which are about to furnish the motor impulse for the 
spasm, the activity of these motor centres is inhibited or arrested 
by the new (more intense ?) irritation. Romberg % % advises the 

* Carpi in Harless Jahrbiicher, Bd. i. Hf t. i. Cited by J. Frank, Praxeos 
Medicae Universal precepta, vol. ii. pars i. p. 965. 

f Dr. Peter Young, loco cit. 

X Dr. Little, in Obstetrical Soc. of Edinburgh, Edinb. Med. Journal, Nov., 
1861, p. 493. 

§ Loco cit. p. 347. 

|| Loco cit. 

If Bauwens, cited in British and Foreign Med. Review, 1836, vol. ii. p. 245. 

'-* Darwin, op. cit. 

ft J. G-airdner, on Anomalous Affections of the Respiratory Organs. Edinb. 
Med. and Surg. J., ii. p. 77. 1840. 

XX Romberg, op. cit. 



124 INHIBITORY ARREST OF SNEEZING. 

use of emetics. Eulenberg * recommends emetics, skin irrita- 
tion (mustard), such tonics as iron, arsenic and quinia. An Eng- 
lish bishop, subject to very harassing fits of sneezing, is men- 
tioned by Watson t as having found an effectual remedy in 
dipping his head into cold water. Alosler controlled the case 
which he reports only by a combination of the warm body bath, 
and cold affusion to the head and back of neck ; a means which 
produced syncope in his weakened patient. 

A number of authors insist upon the necessity of removing the 
peripheral cause, irritation of uterus, etc., if any exist. It would 
seem as if these remedial measures might be properly classed 
under four heads. In the first place, means tending to allay the 
irritation of the nostrils (starch); in the second place, remedies 
which produce, or tend to produce, syncope, and its attendant 
lowering of nervous irritability (emetics, warm baths, narcotics) ; 
in the third place, medicines which, like iron, quinia and arsenic, 
diminish morbid irritability by improving the nutrition of the 
nervous centres ; and fourthly, inhibitory means, such as cold 
to the head and neck, mustard and cantharidal irritation to*the 
neck, inhalation of iodine (Eulenberg 1 , and pressure upon the 
branches of distribution of the infra-maxillary nerve. This last 
measure is the one which has surely arrested or prevented phy- 
siological sneezing in my experience, and in that of many per- 
sons to whom I have recommended it. The upper lip is very 
convenient for this purpose, and the moderately painful impres- 
sion required is easily excited there by the pressure of the side 
of the index-finger. "Whether this simple means would succeed 
in cases of pathological sternutation I will not venture to pre- 
dict. Should it fail, I would suggest as producing a more intense 
irritation of the same nerves, the use of faradization of the skin 
of the same parts (lips and cheeks near nose). The wire brush 
electrode should be used in connection with the secondary cur- 
rent, the skin to be thoroughly dried, and even covered with 
starch-powder. It seems to me rational to anticipate good re- 
sults, also, from the faradization of the nape of the neck in mor- 
bid sneezing, hiccough, or convulsive-cough, after any existing 
peripheral cause shall have been removed. These irritations of 
sensitive nerves (pressure, faradic-current ) transmitted centrip- 
etally by the filaments of the second branch of the fifth pair, 

'■'■'■ Eulenberg. op. eit. p. 673. 

J Watson, Lectures on Physic. Am. ed., p. 110. Phil., 1858. 



INHIBITORY ARREST OF SNEEZING. 125 

or by those of the upper cervical nerves, exert an inhibitory in- 
fluence upon the motor centres which are about to become 
active, viz., the spinal centre of the phrenic nerves in the first 
place, and, secondly, the extensive kinetic tract which is con- 
nected with the muscles of expiration. 

Various therapeutical applications of this method suggested 
themselves to me at the time. 

a. Certain applications to medicine. In various forms of in- 
ternal hemorrhage, especially that occurring in the nasal and 
pulmonary tract, it is highly desirable to avoid the jar produced 
by sneezing. The same indication exists in the course of devel- 
opment of those aneurisms which fall to the care of the physi- 
cian ; for some days after the reduction of prolapsed rectum or 
uterus ; or in the advanced stage of hepatic abscess, or hydatid 
disease. A minor use to which this inhibitory action may be 
put, is the prevention of such pains as are produced by shaking 
of the body, or by deep inspiration. 

K Certain applications to surgery. Sneezing must be avoided 
after many plastic operations, and operations upon the vagina, 
uterus, or abdominal walls. After many cutting operations 
about the eye, absolute rest is highly desirable; and is even 
more required in the cure of cleft-palate. Of course, under many 
circumstances, the arrest of hemorrhage may be made surer by 
the avoidance of sternutation. 

The reader may, perhaps, pardon me if I add a non-medical 
paragraph. The custom of invoking a blessing upon persons 
who sneeze is a most interesting one. Several of the old medical 
authors above referred to state that the custom dates from the 
time of a severe epidemic (in which sneezing was a bad sign) 
during the Pontificate of Gregory the Great. Brand,* however, 
and the author of an article in Kees's Cyclopaedia, t states that 
the phrase " God bless you," as addressed to persons having 
sneezed, is much more ancient, being old in the days of Aris- 
totle. The Greeks appear to have traced it back to the mythical 
days of Prometheus, who is reported to have blessed his man of 
clay when he sneezed4 In Brand, the rabbinical account of the 
origin of the phrase is given as originating in the alleged fact 

* Brand ; Observations on Popular Antiquities, vol. iii. pp. 119-127. Lond., 
1849. 

f Rees's Cyclopaedia, vol. xxxiv. art. Sneezing. 

% Alex. Ross's Appendix to Arcana Microcosmi, cited by Brand, 



126 INHIBITORY ARREST OF SXEEZING. 

that it was only through Jacob's struggle with the Angel that 
sneezing ceased to be an act fatal to man. In many countries 
sneezing has been the subject of congratulations, and of hopeful 
augury. In Mesopotamia and some African towns, the populace 
are reported to haye shouted when their monarchs sneezed." 

* It would be unjust not to state that Diday (op. cit.) had suggested practical 
applications of his method, and that I became aware of this fact only after having 
matured the original parts of this article. 



Kullier. Article Sternutation, Diet, des Sciences med. t. Hi. p. 577, 1821. 

Merlet. Est ne sternutatio naturalis actio ? Paris, 1654. 

Schneider. De osse cribriformi, etc. Wittemb., 1656. 

Schoock. De sternutatione. Amst., 1664. 

Alberti. Diss, de sternutatione. Lips., 1671. 

Birnbaum. Diss, de sternutatione. Lips., 1672. 

Forestus. Diss, de sternutatione. Argent., 1688. 

Hoffmann. (Maurice.) Diss, ptarmographia physiologico-pathologico-thera- 
peutica. Alt., 1710. 

Eyselius. Diss, de stern, praeternaturali. Erf., 1716. 

Rhanius. Diss, de more sternutantibus salutem apprecandi ejusque origine. 
Tigur, 1742. 

Unzer. Diss, de sternut. Hal., 1748. 

Porta. Diss, de sternut. Basil, 1755. 

Buchner (A. L.) De sternut. commodis et incommodis. Hal., 1757. 

Faselius. Diss, de causis sternutationis ejusque effectibus. Ienae, 1765. 

Sidren. Diss, de sternut. Upsal., 1779. 

Van Leempcel. Diss, de sternut. Lovan., 1788. 

Metzger. Diss, de sternutatione. Regiom., 1796. 

Rega H. J. De sympathia, p. 240. Harlemi, 1721. 



DESCRIPTION OF A PECULIAR PARAPLEGIFORM 
AFFECTION. (Tetanoid Paraplegia.)* 

The condition to which I desire to call attention is one which 
cannot be of very rare occurrence, as, in the course of three 
years, I have met with five examples of it. No doubt many 
readers will at once remember having observed precisely similar 
symptoms. 

This form of false paraplegia (using this word as implying the 
existence of paresis or akinesis in the lower limbs), is charac- 
terized by impairment of the functions of the lower extremities, 
when the patient is in the erect posture, without any loss of 
power in these parts. Further analysis shows that the seeming 
paraplegia is dependent upon tonic spasm of the muscles of the 
lower limbs. As negative characters we have absence of the 
symptom ataxia, and often, also, preservation of sensibility. 

The clinical aspects of a case of tetanoid paraplegia are 
the following : The patient complains of having nearly lost the 
use of his lower limbs (he may speak of great " loss of power ") ; 
of having various abnormal sensations in them, and of experi- 
encing trouble in the evacuation of his faeces and urine. When 
the patient is told to get up and walk, he rises with difficulty 
from the bed or chair, assisting himself with his hands. On 
getting into a perpendicular position, with or without the aid of 
a stick, he oscillates a good deal, and seeks to re-establish his 
equilibrium by separating his feet and bending his body for- 
ward. In this posture the knees remain extended, and the feet 
are not averted as in health ; they are often, on the contrary, 
turned inward. The attempted steps are peculiar. The feet are 
not dragged along as in ordinary cases of incomplete paraplegia, 
nor are the knees much flexed, and the feet brought down vio- 
lently as in locomotor ataxia. There is none of the outward 
projection of the entire limb, so characteristic of the latter dis- 
ease. The limbs remain extended, and the feet are simply 
pushed along the floor ; the slight raising of the soles from the 
support being accomplished by a movement involving the entire 

* From the Archives of Scientific and Practical Medicine, Feb., 1873. 



128 TETANOID PARAPLEGIA. 

lower extremity. The tendency of the great toe is downward 
and inward, thus producing, or tending to produce, a partial 
crossing of the limbs, and tripping. If during the efforts the 
observer feel the patient's muscles, he will find them firmly 
contracted. 

If the patient be seated, or made to lie upon a bed, and the 
strength of his lower limbs tested in the usual way, i.e., by bid- 
ding him resist attempts at passive flexion or extension of cer- 
tain articulations, the muscular power will be found almost up 
to the normal limit, if not quite so, in every part of the lower 
half cf the body. There is not, necessarily, any weakness of the 
abdominal muscles. There is, consequently, no paresis present, 
and we cannot correctly speak of the case as one of paralysis. 
The reflex power of the lower limbs, tested in these two posi- 
tions, is found to be much exaggerated, and a state approaching 
spinal epilepsy (a mixture of clonic and tonic spasms) may be 
developed by the examination. Caloric appears to excite these 
reflex actions most readily. 

The state of the bladder and rectum is sometimes peculiar 
(Cases III. and IV.). 

The urine does not dribble away, and exhibits no pathological 
alkalinity. If passed involuntarily, it is at intervals, and by 
jets ; a normal desire to urinate occurring. Usually the patient 
is simply obliged to hurry the evacuation of the viscus, or an 
emission of urine by reflex action will take place very quickly 
after the sensation of fullness has been perceived. One of the 
patients (Case IV.) expressed the state of affairs very well by 
saying,. " Now that I am better, I can go the length of the ward 
before letting go, but no further." The bowels are, as a rule, 
constipated, but when faeces descend into the rectum, a rapid 
emptying of the organ is inevitable. It appears to me reasona- 
ble to suppose that this morbid excitability of the rectum and 
bladder existed in all the cases at some period or other. Ke- 
tention of urine— a truly paretic trouble — is apt to develop as 
the case progresses. 

As above stated, sensibility is not necessarily impaired, and 
in only one case (Case I.) was there much anaesthesia. In two 
cases (Cases II. and III.) sensibility remained normal. It is 
also noteworthy that the existence of considerable cutaneous 
anaesthesia (Case I.) did not at all interfere with the production 
of reflex movements. 



TETANOID PARAPLEGIA. 129 

In no case could true ataxia be made out. The muscular 
sense appeared normal, and what inco-orclination existed was 
due to spasmodic action of the abductor muscles. It will be 
remembered that in ataxia (the symptom) affecting the lower 
extremities, exaggerated action of the abductor muscles is 
present. 

The pathological condition to which these symptoms seemed, 
in all the cases, allied, appeared to be compression of the an- 
terior part of the spinal cord in the dorsal or cervical region. 
In three instances (Cases I., II., and Y.) this can hardly be 
questioned, since kyphosis existed. In Cases III. and IY., I 
admit that the diagnosis of tumor is not established in the most 
conclusive way, but as these patients are still under my obser- 
vation, I may at s©me future time be able to clear up the uncer- 
tainty. As things now stand, I believe that I am authorized to 
conclude that the peculiar false paraplegia caused by reflex 
movements, and to .which I venture to give the name of tetanoid 
paraplegia, is' to be looked upon as a symptom of moderate 
compression of the spinal cord at some point above the lum- 
bar enlargement. I do not wish to be understood as denying 
that tetanoid paraplegia may occur in cases of functional dis- 
turbance of the spinal axis. Although I have seen no such 
case recorded in the publications accessible to me, I have 
no doubt that a similar or analogous state may be observed in 
hysteria. It appears probable to me, however, that in cases of 
increased spinal excitability, without lesion, the spasms would 
be more clonic (saltatory) than tonic (tetanoid) in character. 

The pathogeny of this symptom is similar to that of the 
closely allied (often coexistent) group of symptoms called spinal 
epilepsy. In the first place, as a cause of increased reflex action 
of the spinal cord must be reckoned the diminution of the cere- 
bral influence brought about by compression of the cord. This 
is in accordance wr£h what experimentation upon the lower 
animals teaches us. It is a pretty generally admitted view that 
the cerebral influence moderates the motricity of the spinal 
cord. Another element in the production of these reflex spasms 
I believe (with Dr. Brown-Sequard,* when he speaks of spinal 
epilepsy) to be congestion of the spinal cord below the lesion. 

This symptomatic group evidently belongs to the class of 

- Lectures on the Diagnosis and Treatment of Paralysis of the Lower Extremi- 
ties. Phila., 1861, p. 60. 
9 



130 TETANOID PARAPLEGIA. 

hyperkineses (Komberg), and therefore it may be interesting to 
determine its relationship with some other varieties of increased 
muscular action. 

Its most closely allied congener is spinal epilepsy. This ap- 
pellation was given by Dr. Brown -Sequard to a combination of 
tonic and clonic spasms affecting paralyzed parts in certain 
affections of the spinal cord. He describes it in these terms : 
" Whether spontaneously, or after an external irritation (such 
as a shock, or a pressure on some muscles, tickling the sole of 
the foot, or the passing of a catheter into the urethra), the lower 
limbs are often moved violently or become perfectly stiff ; some- 
times they are drawn up forcibly in a state of flexion, the back 
part of the foot pressing against the hip-joint ; sometimes the 
thighs are drawn violently one against the other by a spasm of 
the adductor muscles, and they press very hard against the tes- 
ticles ; in other cases the flexor and extensor muscles contract 
alternately with great violence, and, after a few minutes of great 
shaking, a rigid condition appears, which, after a time, is fol- 
lowed by relaxation and quietness." * Dr. Brown-Sequard be- 
lieves that " this spasmodic affection of the paralyzed legs is the 
result of the morbid increase in the vital properties of the dorso- 
lumbar enlargement of the spinal cord, owing to two causes : 1st, 
the congestion of that part of the cord ; 2d, the accumulation of 
power in that part of the cord, in consequence of its not being 
any more under the action of the will." He states that the 
pathological conditions which, according to their localities, may 
produce this symptom in man, are localized myelitis, tumors 
pressing upon the cord, fracture and dislocation of the vertebras, 
and that by section of the spinal cord he can easily produce this 
condition in animals. The same group of symptoms, a combina- 
tion of tonic and clonic spasms occurring under similar circum- 
stances, had many years before attracted the attention of several 
observers, and Dr. "William Bucld has left* on record an admir- 
able description of these spasms as observed by him prior to 
1839. t Jaccoud ;f considers exaggerated reflex power in par- 
alyzed limbs in general, and the form of hyperkineses now under 
consideration (spinal epilepsy) in particular, as a positive sign 
of organic paraplegia. 

* Brown-Sequard, op.'cit., p. 59. 

f Medico-Chirurgical Transactions. Vol. xxii. p. 153. 1839. 

X Des paraplegies et de l'ataxie du mouvement. Paris, 1864, pp. 484, 488. 



TETANOID PARAPLEGIA. 131 

A noteworthy variety of spinal epilepsy consists in a succes- 
sion of clonic spasms (trembling) of limited range affecting the 
paretic or akinetic limbs. In case of partial, insulated cerebro- 
spinal sclerosis (and other morbid conditions of the spinal cord), 
this trembling may be excited by irritation of peripheral nerves ; 
and forcibly flexing the foot (patient being in recumbent position) 
seems to have special efficacy. A similar movement may be 
produced in healthy individuals by insufficient and ill-placed 
support of an extremity : a foot, for examjole. 

The spasm which constitutes the most imjDortant element in 
the obscure affection known as writer's cramp is analogous 
to tetanoid paraplegia. Here the patient, while writing the 
first few words experiences no marked difficulty, but after the 
spinal cord has been acting for some time, a spasm, more or less 
tonic in character, affects the flexor muscles moving the thumb 
and fingers, and there ensues an illegibility in the writing, or an 
utter impossibility to hold the pen. The same spasm of the 
flexors occurs when the patient is using his fingers for other 
purposes, such as holding a cup or saucer ; never spontaneously. 
We thus have hyperkinesis determined by the action of a periph- 
eral irritation upon a functionally diseased nervous centre. 

There is, it seems to me unquestionable, a spasmodic element 
in the complex group of symptoms which constitutes the disease 
known as locomotor ataxia. In the first place, as believed by 
Brown-Sequard,* the conservation of force in the lower limbs, 
in the paraj)legic forms of this disease, is only apparent. I am 
ready to admit, with him, that a certain degree of paresis exists 
in the affected parts, but that the methods employed for testing 
the degree of volitional force really develops a degree of reflex 
(morbid) power which, after the first moments of the examina- 
tion, conceals whatever loss of power may previously have 
existed, and causes even an abnormal degree of muscular strength. 
Secondly, in the symptom ataxia, I have for some time believed 
that the characteristic disharmony in the action of various mus- 
cular groups in the ♦ typical stages of the disease locomotor 
ataxia, was due not so much to diminished nervous influence in 
the muscles overcome by their antagonists, but in increased 
motricity sent to the over-acting muscles. Thus, in the jerking, 
externally projected steps there is an overbearing action of the 

* Oral communication, 1869. 



132 TETANOID PARAPLEGIA. 

abductors and extensors, and this is due, in my opinion, to the 
reception of abnormal increased motricity by these muscles ; a 
motricity developed in a reflex way by the exercise of the limbs 
(see above, writer's cramp). I am aware that recent writers are 
inclined to consider the disharmonious action above referred to 
as wholly dependent upon varying degrees of impairment of the 
muscular sense. If this be so, why should the disturbance 
affect definite muscular groups ? 

Certain forms of contracture of the paralyzed limbs in hemi- 
plegia (of cerebral origin) bear a very close resemblance to the 
false paraplegia I have endeavored to describe. There is now a 
male patient under my care at the Epileptic and Paralytic Hos- 
pital, Blackwell's Island, who experienced months ago an ordinary 
apoplectic stroke, followed by right-sided hemiplegia (including 
face), and temporary aphasia. He has recovered some degree 
of voluntary motion in the palsied limbs, but suffers much from 
contracture of the arm and hand. The resident physician, Dr. 
Bruce, the nurses, and the patient himself assure me that at 
night and in the early morning, before exposing the parts to the 
air, or attempting to rise, the hand lies quite open and relaxed, 
and that no stiffness whatever exists at the elbow-joint. The 
contact of air, however, and, more surely, the acts of rising and 
stepping upon the cold floor, provoke a spasm which in a few 
minutes reaches its maximum. TVhen this is at its highest de- 
gree of tension (as it is during my visits) the forearm lies across 
the chest (patient sitting in a chair or walking), the elbow being 
bent about at right angles ; the wrist is somewhat flexed, and the 
finger-nails are forced into the palms of the hand. The observer's 
efforts to overcome this contracture only increase it, and the 
same is true of the patient's own volitional efforts, and of his 
using the other limbs. The right lower extremity is moderately 
stiffened, in extension, during waking hours. The flexors and 
adductors of the upper extremity have not suffered in nutrition, 
while the overpowered (stretched) extensors are in a state of 
unmistakable atrophy, and have lost eleetro-muscular contrac- 
tility. The pathological physiology in this case I believe to be 
precisely similar to that explained when speaking of tetanoid 
paraplegia. The principal cause of spasm (increased reflex 
power) in both cases is the separation of the spinal axis from 
the cerebrum : in the false paraplegia the cutting off occurs 
somewhere in the spinal cord, while in hemiplegia it happens at 



TETANOID PARAPLEGIA. 133 

the junction of the upper end of the spinal axis with the cere- 
brum (corpus striatum). 

I wish to add a few words concerning a form of " stiffness " 
of the lower limbs which is much complained of by patients 
having congestion (?) of the spinal cord and its meninges. This 
is a purely subjective sensation which accompanies the numbness 
and formication which form such prominent features in these 
cases. The " stiffness " as well as the numbness are worse when 
the subject is lying down or sitting, and are greatly felt during 
the first efforts at movement. Contrary to what obtains in spas- 
modic paraplegia, this feeling grows less marked after the 
patient has taken active or passive exercise. There is no real 
(objective) rigidity, and reflex movements are not necessarily 
modified from the healthy standard. 

As regards bibliography I can say but little. Only one writer, 
to my knowledge, seems to have noticed and described a condi- 
tion similar to the one forming the subject of this contribution. 
I refer to Jaccoud,'* who, in his valuable work on various forms 
of paraplegia, gives a page and a half to what he calls false 
paraplegia, due to exaggerated spinal excitability. He does not 
refer to any cases, nor does he give any account of the patho- 
logical conditions accompanying the symptom. He undoubt- 
edly has seen cases similar to mine. I have come across a ref- 
erence which may be thought to indicate that the physician 
referred to had seen and described spasmodic false paraplegia. 
E. Goupilf made (ever published ?) a classification of hysterical 
paraplegias, embracing the following varieties : 1st. Hysterical 
paraplegia due simply to muscular weakness ; 2d. Hysterical 
paraplegia produced by the extreme pain caused by reflex action 
and movement ; 3d. Hysterical paraplegia produced by loss of 
muscular sensibility. While admitting that Goupil's second 
variety bears a certain resemblance to tetanoid pseudo-para- 
plegia, I would recall that in the cases'! am about to detail, pain 
on movement was not a feature, and that hysteria had nothing 
to do with any one of my five instances. The older and more 
recent treatises and monographs upon diseases of the nervous 
system, with the above exception, contain no reference to the 
condition I have described.^ 

* Jaccoud, op. cit. pp. 469-471. 

f Cited by Leroy: Des paralysies des membres inferieures. Paris, 1856; p. 210. 

X After the above had been printed I had the opportunity of reading Hallo- 

peau's interesting thesis entitled Des accidents convulsifs dans les maladies de la 



134 - TETANOID PABAPLEGIA. . 

Case I. — By the kindness of Dr. Gustavus A. Sabine, I had the opportunity 
of studying the symptoms presented by Mr. P., an Englishman, aged 46 
years. About six weeks before the consultation (April 6, 1872) patient 
noticed, while at first walking in the morning, a slight degree of numbness 
and formication with " loss of power " in the lower extremities. The numb- 
ness affected all the parts below the knees, and to a much less degree the 
anterior surface of thighs. At same time, or shortly after, he observed 
twitching of the lower limbs at night. These three symptoms — formication, 
"loss of power," and twitching — progressively increased, until he now walks 
with difficulty, even when aided by a stick. Yesterday was obliged to ask 
assistance to cross a busy thoroughfare. The bowels have been costive and 
the urine hard to pass. Since three weeks has felt as if a band were tightly 
drawn around the lower part of the abdomen. Lower limbs have moder- 
ately wasted. The " loss of power" has rapidly increased in the last three 
days. 

The examination shows nothing abnormal about the upper part of body 
excepting the fact, that the pupils are extremely minute.* The co-ordination 
of the upper extremities is perfect. The patient walks in a peculiar way. He 
leans firmly upon a stick, and takes very short steps with limbs almost per- 
fectly rigid. There is neither distinct jerking outward of the feet nor drag- 
ging; but patient staggers much. Stands with feet somewhat separated, and 
without stick oscillates a good deal. The walk is not made different or 
worse by closure of eyes. Strength of lower limbs, tested in sittiug and 
recumbent postures, shows very slight, if any, impairment. Movements well 
co-ordinated. Some disturbance of sensibility; superficial contact not nor- 
mally perceived, impressions of pain retarded and metamorphosed into burn- 
ing. Localizes impressions well, and sense of temperature is normal. Reflex 
movements exaggerated. Lower abdominal muscles weak; cause of consti- 
pation and slow micturition. No spontaneous pain in back or limbs. Deep 
pressure reveals obscure tenderness on level of fifth and sixth dorsal vertebrae. 
Patient states that stiffness in limbs and back is worst in early morning, and 
is somewhat relieved by exertion. Twitching of legs increased; often has 
alternations of clonic and tonic spasms (spinal epilepsy). On the 23d a second 
examiuation shows continuance of numbness and stiffness. Cramps decidedly 
less. Rather more impairment of sensibility; pinching produces severe 
burning. Patient loses his limbs in bed ; once attempted to rise in dark, and 
failed to "strike bottom" with his feet; found himself on his knees. Is un- 
conscious (eyes closed) of passive movements below hips. Co-ordinates well. 
May 3d. The obscurity of the case is to-day cleared up by the discovery of a 
slight but distinct angular curvature of the spine, caused by projection of 
spinous processes of fifth and sixth dorsal vertebrae. Deep pressure produces 
pain. A few days later the patient started for England. 

moelle epiniere, Paris, 1871, in which I find a case of false paraplegia caused by 
spasm, well described (Case III., p. 5C). The author correctly appreciates the sig- 
nificance of the symptom, but has not called attention to it specially in his 
remarks. 

* It may be interesting to state that the patient's brother, an apparently 
healthy man, has similarly small pupils. 



TETANOID PARAPLEGIA. 135 

Cass II. — J. H., male, aged 32 years, in my service at the Epileptic and 
Paralytic Hospital, BlackwelFs Island. Patient was first admitted in March, 
18G9, discharged, and readmitted in Jnly, 1870. Two histories of the ca*se 
are on record, which differ somewhat as to the mode of reception of the in- 
juries, which produced various symptoms. There is no conflict, however, on 
the points which render the case interesting in the present connection, viz., on 
the state of the spinal column and of the lower limbs. I will abridge from 
both accounts, one of which was written at the bedside under my own dictation. 

Eighteen years ago a chimney fell upon patient and produced a compound 
fracture of the skull, necessitating the removal of large pieces of bone. Xo 
paralysis resulted from wound or operation. Now bears a large scar on left 
side of vertex, six inches in length (antero-posterior), three-quarters inch 
at widest part, and in some places it is three or four lines deep. The 
scar extends a little across the sagittal suture. The pulsations of the brain 
are distinctly felt through the cicatrix. About two years ago (1867), a car- 
riage passing over him, he was kicked in the back, and his spine vi broken." 
After this accident he was able to walk, though with great difficulty. In 
January, 1870, felt ''rheumatic pains all over,'' and in the spring went into 
Bellevue Hospital. The legs felt "dead "' to him, and no jerking was pres- 
ent. TThile in Bellevue had more or less retention of urine, and the catheter 
was sometimes used. The right leg was flexed for five weeks, the left never, 
but both were stiff and strongly adducted. 

Condition on July 7th, 1871. Lies in bed; can raise each heel four or five 
inches from bed, and can voluntarily move every articulation of lower limbs. 
Strength seems to be perfect in lower extremities ; voluntary adduction being 
almost impossible to overcome. Reflex movements are very violent. In the 
erect position the movements of the legs are but little subordinate to the will. 
The patient can hardly stand, even with the support of crutches; when 
movement is attempted, but slight motion is seen at knee-joint. [I may here 
add that I remember most vividly what is not sufficiently entered in the 
record, viz., the patient's very peculiar attempt at walking. He would get 
out of the bed with help, his legs being moderately rigid, but the moment 
his bare feet touched the floor, most severe reflex movements occurred, pro- 
ducing tetanic rigidity of the limbs. Holding on by the head of the bed, a 
chair, or an attendant's arm, he could take a few steps, which consisted in 
sliding of the feet a little way, no hip or knee or ankle movement being 
apparent. He was also conscious of a tendency to adduction and crossing of 
legs.] Sensibility seems in all respect to be good (increased?) in lower 
limbs, and patient feels some numbness, more on right side. Upper extremi- 
ties in normal state ; bears marks of bed-sores on hips and sacrum. Spine 
exhibits kyphosis in its middle dorsal region, accompanied by slight scoliosis 
to the left. The greatest angular curvature is on level of fifth and sixth 
dorsal vertebrae. No difficulty in making water; bowels costive. At a later 
period the patient died of extensive erysipelas, but no autopsy could be 
obtained of the friends. I had diagnosed compression of the spinal cord by 
the products of broken-down vertebra?, there having been a traumatic Pott's 
disease. At one time there must have been much localized meningitis and 
perhaps superficial myelitis. 



136 TETANOID PARAPLEGIA. 

Case III. — J. A., male, aged 38 years, admitted to the Epileptic and Para- 
lytic Hospital, September 8, 1872. At first a painter, but during the last few 
years following the sea. Never had constitutional syphilis, rheumatism, or 
painter's colic. In October, 1870, while on a voyage from Italy to New York, 
he had an attack, which he thought was rheumatic, caused by constant 
exposure and overwork. His symptoms were severe pain in lower extremities, 
and a sensation as if a heavy weight were attached to all parts below the waist 
and were dragging him down. Has since had much pain, principally in left 
thigh, and has gradually lost use of lower limbs. In March, 1872, he was 
attacked at night with trembling of left upper extremity, accompanied by a 
feeling of numbness, and he has since progressively lost the power of moving 
his left hand. About September 1st, similar symptoms (trembling and 
numbness and subsequent palsy of hand) affected the right arm. At the same 
time a pain appeared in the left fifth intercostal space, a little outside the 
nipple, and this pain has remained. No head symptoms excepting occasional 
attacks of dizziness. Shortly before admission patient began to experience 
trouble in retaining his urine. It did not dribble away, but after a small 
quantity had accumulated in the bladder the desire to urinate was irresistible 
and the viscus was often suddenly and involuntarily emptied. At the begin- 
ning of November, 1872, I made an examination of this patient. The mouth 
is notably drawn downward on the right side ; tongue projects straight out ; 
the orbicularis oris cannot be fully contracted, so that whistling is very im- 
perfectly done. No stammering, but speech is a little thick. Pupils normal, 
and sensibility good on all parts of head and face. The upper extremities 
exhibit paresis at shoulders and elbows, with very marked atrophy of many 
muscles of the hand, those of the thenar and hypothenar eminences, and nearly 
all the interossei. Fibrillary movements are distinct in many muscles of the 
upper trunk and arms. Sensibility in its various modes is perfect. There is 
no atrophy, paresis, or anaesthesia about trunk. The lower extremities present 
peculiar symptoms. The patient cannot stand erect with his bare feet upon the 
floor ; with his shoes on he can stand with help of nurse, and by great effort. 
During the attempt he oscillates greatly. While walking with help, slides 
both feet along in an equally awkward w T ay ; does not jerk or drag them. 
During these efforts, standing or walking, the muscles are rigid. Patient says 
that his legs feel stiff. Closing eyes does not make the attempt at standing 
worse. Examined in the recumbent posture, all movements are performed by 
lower limbs with effort, but with perfect co-ordination. Efforts cause more 
or less clonic spasms in lower limbs, and a pain in masses of muscle forming 
anterior part of thighs. Scratching soles, or other modes of irritation (cold 
impressions especially) produce strong reflex movements, mostly clonic. 
Strength at various joints perfect. Fibrillary movements in muscle are excited 
by filliping the skin. The various modes of sensibility are normal. The 
patient has observed that his legs stiffen when the cold air first strikes them 
on getting out of bed. The bladder trouble is as above described, an incon- 
tinence through spasm. The diagnosis of tumor compressing the spinal cord 
(incipient Pott's disease ?) is made from co-existence of referred pain to legs 
and left side, of false paraplegia (tetanoid), and atrophy of a few muscles of 
upper extremity. This last symptom is explicable by compression of some 



TETANOID PARAPLEGIA. 137 

anterior roots of nerves. The seat of compression is probably at the upper 
part of the cervical enlargement. 

Case IV. — J. R., aged 42 years, a baker of intemperate habits, and admit- 
ting great sexual excesses, in 1864 had primary sore and secondary syphilitic 
symptoms. During the fall of 1869 he suffered from pain in the 'right side, 
and later, in the back ; this being made worse by motion. March 6th, 1870, 
he awoke with both legs numb, accompanied by retention of urine. Admitted 
into the Epileptic and Paralytic Hospital, bearing a large bed-sore on sacrum, 
and having a paraplegia characterized by numbness and excessive reflex 
action. Before admission reports that he could not move lower limbs in the 
least. Improvement began in July ; noticed sensation of distended bladder, 
acquired some voluntary movement of both legs; more control, over left. 
Was unable to control rectum and bladder. Improved much under hypo- 
dermic injections of strychnia ; bed-sore healing. During 1871-2 had iodide 
of potassium in large doses. I was inclined to consider the paraplegia one 
dependent upon a syphilitic lesion of the spinal dura mater, causing pressure 
and irritation. Discharged in early summer of 1872, able to walk with 
crutches, and gaining. Examination in supine position shows that voluntary 
movements of left lower extremity are very free ; can raise foot more than 
twenty inches from the bed. Right foot can be raised only about ten inches. 
Strength at various joints (resistance to passive movements) normal. Has 
much twitching and spasm in lower limbs. Appreciates surface contact and 
tickling, but does not localize impressions correctly. Sense of temperature 
and of pain normal. Reflex movements produced by examination of sensibil- 
ity. Both legs feel numb below knees. Patient bears large node on the 
right tibia. 

Re-admitted in fall of 1872. Examination January 5th, 1873. Walks with 
help of crutches, or of a stick. Steps small, legs tend to cross one another 
(adduction), and the lower extremities are apparently stiff. Patient has 
noticed great spasm in them at times, on standing up. In supine position 
voluntary movements of the left lower limb are normal in extent ; flexion of 
thigh and knee on right side is limited by stiffness at knee and hip joints. 
Power of resistance at both knee-joints normal ; as also at other joints of 
lower limbs. Reflex excitability increased, more on the left than on right 
side. Co-ordination of movements (eyes closed) quite perfect. Is conscious 
of passive movements at knee-joints ; unconscious of them when made at 
ankles and toes. Sensibility preserved except as regards the tactile sense, 
which is much impaired on feet. 

The patient states that his bad walking is due to stiffness of the limbs. 
When he attempts to stand alone in bare feet, the reflex spasm is so great as 
to cause him to lose his balance ; with help, and in stockings and shoes, can 
walk as above described. Has better control over his legs some days than 
others. His urine docs not dribble away nor is it retained, but when the 
desire to urinate is felt he must empty the bladder almost immediately, or the 
urine is forced out against his will. Is improving while taking large doses 
of iodide of potassium. 

Case V.— J. K., male, 36, admitted to the Roosevelt Hospital, service of 
Dr. W. H. Draper, February 9, 1872. In March, 1871, patient began to suffer 



138 TETANOID PARAPLEGIA. 

from pain in his spine, about the level of the third and fourth dorsal vertebrae ; 
and about the middle of April he noticed a tumor, about as large as a small 
hen's egg. in the same locality. The tumor grew and the pain became more 
severe until May, when the application of a plaster is said to have caused both 
pain and swelling to disappear. 

Late in December, the pain and tumor coincidentally returned, and about 
one month ago patient observed weakness in his legs, most marked in the 
right. The tumor has been stationary since the beginning of the year. Ex- 
amination of upper limbs reveals nothing abnormal. Over third dorsal ver- 
tebra is a firm, slightly reddened tumor, about the size of half an egg ; 
this tumor is painful when firmly rjressed. Intercostal muscles act very 
slightly ; respiration mostly abdominal : marked impairment of sensation, 
motion and co-ordination in the lower limbs : worse on right side ; bowels 
torpid. When he wishes to urinate, he is obliged to do so at once. February 
IT. is much troubled by reflex contractions. Examined by Dr. Seguin at Dr. 
Draper's request. Marked loss of sensibility in right leg ; lessened sensibility 
in left. Co-ordination in both legs impaired. Resistance to flexion of knee 
nearly normal while lying on back, but when upright this is notably lessened. 
I have a very clear remembrance of this examination, and will add to the short 
entry made at the hospital. The " in-co-ordination " consisted in extraordi- 
nary stiffness of the lower limbs, when the patient attempted to walk with 
the aid of a nurse. At the same time the feet tended to cross each other from 
strong action of adductor muscles. In the recumbent posture no trace of in- 
co-ordination appeared, and there was almost perfect strength in all parts of 
the lower extremities. It was this wonderful contrast between seeming 
extreme paraplegia when standing or attempting to walk, and the preserva- 
tion of motor power when lying on back, that caused surprise to all present. 
At the same time I made out a decided angular spinal curvature involving the 
third and fourth dorsal vertebra?, and decided that the case was one of Pott's 
disease of the spine. February 20th. more pain in tumor. Incision causes 
escape of blood only. March 1st. retention of urine has appeared ; cathether 
used. Angular curvature more pronounced. March 10th. reflex movements 
in legs very annoying ; great dyspnoea. April 10th, urine dribbles away ; 
bed-sores forming over sacrum and trochanters. Spinal angle increasing. 
During succeeding months the bed-sores extended greatly, the spinal curve 
became more acute, and power in legs was reduced to a minimum. After 
living for a month and a half at the point of death, patient expired July 9th. ] 

I am indebted for the above history to Dr. X. B. Sizer, House Physician to 
the Presbyterian Hospital : and wish to express my thanks to Dr. Robert F. 
^Veir, Surgeon to the Roosevelt Hospital, for permission to make use of the 
case. 



LECTUEE UPON THE GENEKAL THEKAPEUTICS OF 
THE KEBVOUS SYSTEM* 

Gentlemen : — I have thought that the last hour of jour sur- 
vey of nervous diseases could not be better spent than in a 
rapid review of certain principles of therapeutics, and in a par- 
tial study of the remedial agents classified as much as possible 
in accordance with these principles. In offering you the follow- 
ing classification, I wish to warn you that it has little in com- 
mon with the therapeutic propositions which you will find in 
text-books, whether upon the practice of medicine or upon dis- 
eases of the nervous system. Inasmuch as the ground to be 
gone over is so large, you will pardon me if I restrict myself to 
short practical remarks upon the various heads of the lecture. 

The following is the classification which I have long had in 
my mind, and which I now submit to you : 

CLASSIFICATION. 

f 1. Agents which increase the blood- 
a— Agents which affect the blood- ! supply. 

supply of nervous system. | 2. Agents which diminish the blood- 

l supply. 

f 1. Agents which in- j a, brain. 
B — Agents which affect the substance J crease action of \ 5, spinal cord, 

of nervous system. j 2. Agents which di- \ a, brain. 

[ minish action of ( b, spinal cord, 
c — Restoratives and Tonics. 
d — Counter-irritants. 
e — Electricity. 
F — Hygienic means. 

Class A. 
Means ivhicJi Affect the Blood-supply. 

The indication for affecting the blood-supply of a nerve-centre 
is sometimes a perfectly correct and logical one. 

In practice, we have a certain class of cases in which the 
symptoms are due to hyperemia of nerve-centres, and also a 

* Delivered at the College of Physicians and Surgeons, Xew York, Feb. 21, 1874. 
From the X. T. Medical Record, June 1, 1874. Vol. ix., p. 281 et seq. 

[This lecture was reprinted in full by the London Medical Record. — K. W. A.] 



140 GENERAL THERAPEUTICS OF THE NERVOUS SYSTEM. 

certain class in which the symptoms are due to anaemia of nerve- 
centres. 

The vital question is to determine whether the hyperemia or 
anaemia be primary or secondary. 

Few questions in pathology are of more importance than this, 
and few have caused such prolonged discussions. This is not 
the place to examine this matter, and 'I must limit myself to 
stating the conclusions to which experience has led me. I be- 
lieve that true primary hyperaemia of the brain or spinal cord 
is a very rare affection, infinitely rarer than the teaching of 
books would lead us to suppose. In many so-called cases of 
cerebral congestion there is, I believe, no hyperaemia, but only 
mal-nutrition, which may be attended by a secondary and pas- 
sive congestion. In all such cases the leading indication is not 
to deprive the nervous centre of blood. The effects of anaemia 
are better known and more commonly observed ; and it is an in- 
structive fact to recollect that what we to-day consider as typical 
of anaemia (epileptic loss of consciousness) was not many years 
ago looked upon as typical of hyperaemia. In brief, I believe 
that the indication to diminish the amount of blood circulating 
in the brain (and spinal cord) is very rarely presented to us 
practitioners, and that the contrary indication is much more 
commonly encountered. 

The first class of means is subdivided into two sub-classes : 

(1) Means which increase the blood-supply. 

This sub-class may be still further subdivided as follows : 

(a) Decubitus, or posture. 

(b) Compression of arteries of limbs. 

(c) Stimulants. 

(d) Agents paralyzing the vaso-motor nerves. 

(e) Measures which act by increasing the activity of the nerv- 
ous centres. 

(a)-The amount of blood in the spinal cord can be materially 
increased by placing the patient upon his back. 

The amount of blood in the brain can be materially increased 
by elevating the legs and arms. 

In syncope, therefore, and in all cases where we may suppose 
that anaemia of the brain is present, the first thing to be done is 
to place the patient upon his back, and we may, besides, elevate 
the limbs and trunk. Anaemic patients, who have no positive 



GENERAL THERAPEUTICS OF THE NERVOUS SYSTEM. 141 

disease, but who at times feel weak, and faint, or suffer from at- 
tacks of vertigo, should also have recourse to this means. 

(^-Compression of the arteries of the limbs is a very impor- 
tant and powerful means. 

This should be done by tourniquets, as ordinary bands alone 
will not 'arrest the circulation carried on through the arteries, 
but will prevent the return of blood to the body. 

This procedure is one whi<^h is rarely resorted to, and I would 
recommend its execution only in extreme cases of cerebral 
anaemia, as a means next to transfusion. The tourniquets should 
be applied not simultaneously, in order that you may study the 
reaction of the heart. 

In the days when epileptic seizures were regarded as due to 
cerebral hyperemia, compression of the carotids was advised 
and done to cut short the paroxysms. Insensibility can in this 
manner be produced in the healthy individual. In epileptics 
the results obtained were not satisfactory, and the measure is 
one we now condemn as unphysiological. Besides, in pressing 
upon the carotid we act upon the vagi, and influence the heart 
in that way. 

(c)-Of the stimulants, alcohol is the best. Preparations of 
ammonia are employed, but they are less efficient than alcohol. 
The dose of alcohol in cases of anaemia of the nervous centres is 
to be gauged only by the degree of reaction observed. In the 
drowsiness and exhaustion which result from prolonged exposure 
to cold with or without over-exertion, in cases of loss of blood, 
brandy will be tolerated in enormous quantities, and the subject 
saved. 

In general terms food is to be regarded as a stimulant, for the 
general circulation is made more active by taking it. Probably 
many of you have had an afternoon headache magically cured by 
dinner. 

(cZ)-Paralyzing the vaso-motor nerves, by producing enlarge- 
ment of the arteries, is productive of hyperemia in the arterial 
district to which the nerves are distributed. 

This proposition is demonstrable by experiment upon animals. 
If we cut the sympathetic nerve in the neck (as was done by 
Pourfour clu Petit in 1712), we obtain a dilatation of all the ar- 
teries of the superficial parts of the head, and of all parts of the 
face, together with contraction of the pupil. As signs of hyper- 
emia, we observe increased size and pulsation of arteries, red- 



142 GENERAL THERAPEUTICS OF THE NERVOUS SYSTEM. 

ness, increased heat, increased secretory action. If we excise 
the superior cervical ganglion of the sympathetic, we produce 
hyperseuiia of the brain itself. In medicine we cannot resort to 
this radical means of paralyzing the vaso-motor nerves. 

Of means to be used for this purpose, the most effectual is 
inhalation of the nitrite of amyl. The proper dose is from two 
to five drops. 

If the remedy is to be administered by the medical attendant, 
it needs no preparation ; iaxe to ten drops may be poured upon 
a cloth or handkerchief, and a part or the whole of the quantity 
allowed to enter the patient's nostrils. In many cases the phy- 
sician is away during the illness or seizure requiring the use of 
nitrite of amyl, and the nurse may give it safely, diluted in alco- 
hol in such a way that a teaspoonful shall hold the proper dose. 

The effects of amyl, apparent in a few seconds, consist in 
hyperemia of the head and face, of increased heart action, and 
of redness and heat in the remainder of the body sometimes. 
From the condition of the face and external parts of the head, 
and from the sensation of fullness in the eyes and within the 
head, associated often with giddiness, we infer that there is 
hyperemia within the cranium as well as without. 

One indication for the use of this remedy we find in the con- 
dition present at the commencement of an epileptic convulsion. 
In the very earliest stage, during the occurrence of the aura, or 
the period preceding the aura, which is recognized in some pa- 
tients, is the proper time to resort to this remedy. If used then, 
or at the moment the spasm of the vaso-motor nerves com- 
mences, indicated by the first signs of failure of consciousness, 
in many cases the attack can be averted ; in others diminished 
in severity. Nitrite of amyl has also been used with success in 
angina pectoris, in asthma, and in various spasmodic affections 
involving muscular or vascular parts. • 

Chloroform has been used in the same manner, but its mode 
of operation is unknown, and it is much less effectual. 

Another means is by over-stimulating the sympathetic nerves, 
but this means cannot be employed with any great degree of 
certainty. This is more theoretically than otherwise correct 
(vide infra, sub-class 2, e).' 

(e)-The means which produce functional hyperemia are ex- 
ceedingly numerous, embracing as it does all those agents which 
increase the activity of the nervous centres. 



GENERAL THERAPEUTICS OF THE NERVOUS SYSTEM. 143 

Hyperemia of the nervous system occurs as the result of 
functional activity in the same manner as it is developed in the 
various organs of the body as the result of the same cause ; such 
as the congestion present in the stomach and intestines and 
liver during digestion, etc. In this connection it is well to re- 
member that it has been shown that increased temperature about 
the head is developed during exercise of the mental faculties, or 
by the operation of emotion. 

The medicines referred to will be found in class B, sub-class 1. 

(2) The second sub-class of A embraces all the means em- 
ployed to diminish the amount of blood circulating in the nerv- 
ous centres. 

(a) Venesection. 

(b) Decubitus. 

(c) Compression of veins of the limbs. 

(d) Cold. 

(e) Those means which stimulate the vaso-motor nerves. 

(/) Means which diminish the activity of the nervous centres. 

(a)-There can be no doubt that blood-letting, if sufficiently 
large, will produce cerebral anaemia, for although physiologists 
still believe that the quantity of contents of the cranium is in- 
variable, yet they to-day admit that the amount of intra-cranial 
blood may be reduced, serum taking its place about the vessels 
and in the sub-arachnoid space. I need hardly tell you that 
bleeding is out of fashion, and that we nowadays never use it. 
I would, however, say that with sufficient symptoms of sudden 
and violent cerebral hyperemia occurring in a subject full- 
blooded enough not to be injured by the loss, I should bleed 
without hesitation by a large opening, and to impending 
syncope. 

It is perhaps right for me to speak here of leeches and wet 
cups, in order to express my belief that these agents do not 
relieve hypersemia of deeply placed organs so much by with- 
drawing blood as by irritating nerves, and thus acting upon the 
vaso-motor nerves of the affected parts. These means should 
therefore be placed in class D, with counter-irritants. 

(&)-If the brain is the nervous centre to be affected, the 
decubitus should be with the head raised ; or the patient should 
be placed in a chair with his legs and arms in a pendent posi- 
tion. This latter posture is useful in certain cases (rare, I 



144 GENERAL THERAPEUTICS OF THE NERVOUS SYSTEM. 

believe) of insomnia dependent upon true primary cerebral 
hyperemia. 

In cases of spinal congestion, myelitis, or any affection of the 
spinal cord attended by congestion, place the patient upon his 
face. Relief may be secured by permitting the patient to occa- 
sionally lie upon the side, but lying upon the back should be 
almost entirely forbidden. 

(c)-Compression of the veins of the limbs may be effected by 
means of ligatures. Formerly employed in convulsive affec- 
tions, it has now fallen into almost complete disuse. 

(c£j-Cold, when used in a proper manner, undoubtedly has 
the power of diminishing the amount of blood in a part deeper 
than the skin. It must, however, be applied continuously if 
any benefit would be derived. 

In the treatment of meningitis and all affections in which 
there is present hyperemia, either primary or secondary, within 
the cranium, ice should be placed upon the head and at its base 
for considerable periods of time, carefully watching the effects 
in order to remove it at once if there is evidence that too 
much depression is being produced. 

The same means may be used with benefit in intra-spinal 
inflammation and congestions. 

Cold is also applied to the back of the neck and upon the 
spinal column with the object of acting, through the spinal cord, 
upon the vaso-motor nerves going to distant organs. 

A word as to the means of using cold. You will hear Chap- 
man's rubber bags highly recommended, but I suspect that their 
cleanliness and ease of application are what have caused their 
fame. It is best to apply the ice in block immediately to the 
skin, well guarded by cloths to catch the drippings ; or pounded 
ice (with or without salt), inclosed in a cloth or bladder, may be 
used ; or, lastly, the ether-spray douche may be employed. 

(e)-The vase-motor nerves may be directly stimulated by 
galvanism, causing contraction of the arteries supplied by these 
nerves and consequently anaemia of the parts to which these 
arteries go. This may be experimentally demonstrated for the 
face by galvanizing the sympathetic in the neck ; for the fundus 
of the eye and the brain, by localizing the action of the current 
upon the superior cervical ganglion. The positive pole should 
be applied under the ear, in front of the mastoid process (small 
electrode), the other electrode be placed upon the fifth cervical 



GENERAL THERAPEUTICS OF THE NERVOUS SYSTEM. 145 

vertebra ; the current of from 4 to 8 Stohrer's cells allowed to 
pass for one to two minutes. 

Evidence of spasm of the cerebral arteries is obtained in the 
shape of vertigo developed at the moment of closing and opening 
the circuit. The vessels of the' fundus of the eye have been seen 
to grow smaller under this amplication. Anaemia of a part of 
the brain is no doubt the inevitable immediate result of thus 
irritating the superior cervical ganglion, but a law of physiology 
stands in the way of our accepting this as a means to be used 
to meet the indication of diminishing the supply of blood. The 
law I refer to is that of never-failing relaxation after spasm, of 
exhaustion after stimulation. This law leads me to believe that 
after the primary cerebral anaemia produced as above described, 
there is a consequent equally inevitable relaxation of blood- 
vessels and hyperaemia produced. This is how I would justify 
the placing of this means, galvanization of vaso-motors, among 
those which increase the amount of blood in the brain {vide 
supra, sub-class 1, d). 

Among medicinal agents, I know of few which will stimulate 
the vaso-motor nerves which are not medicines that should be 
embraced in another class. One exception, perhaps, is ergot. 

Some recent observations seem to indicate that ergot di- 
minishes the amount of blood circulating in the spinal cord and 
in many other tissues. It has been demonstrated that bella- 
donna in small doses will accomplish the same thing. These 
two remedies, therefore, are quite generally used in the treat- 
ment of congestions and inflammations affecting the nervous 
centres. We are indebted to Dr. Brown-Sequard for their 
introduction into practice upon correct indications. 

(/)-Dimrimtion of the activity of the nervous centres may be 
brought about by mental and physical rest. By mental rest I 
understand not inactivity, but a cessation of the strain, intel- 
lectual or emotional, which has acted upon the patient. The 
merchant or professional man should diminish or cease altogether 
his work, whether in the way of actual labor or responsibility ; 
he should resort to other occupations and to amusement. On the 
contrary, the emotional girl, or the insane subject, should be 
given work, physical if possible, in order to withdraw the atten- 
tion from the contemplation of delusive sensual or pure emotional 
subjective creations. The operations of grief, of misery, of 
concentration in a diseased self, should be remedied by a variety 
10 



146 GENERAL THERAPEUTICS OF THE NERVOUS SYSTEM. 

of means (including amusements) which will suggest themselves 
to you. At all events, please remember that mental rest is not 
synonymous with inertia or idleness. 

Physical rest is of great utility, and has been employed in 
locomotor ataxia with especial benefit. , 

Various remedies may be used for the purpose of diminishing 
the activities of the nervous centres, and these will be referred 
to in sub-class 2 of the next class, B. 

Class B. 
Means which Affect the Substance of the Nervous Centres. 

(1) Agents increasing action of nervous centres — Excitants. 

By nervous excitants I understand such means and medicines 
as produce (or can produce) an immediate stimulant effect upon 
the nervous centres, independently of any corresponding increase 
in vascularity. The certainty (specificity ?) and rapidity of 
their action distinguish these medicines from tonics. 

f Alcohol, embracing wines, brandies, etc., Canna- 
(a)— Cerebral J ^is Indica. 
excitants. I Belladonna, Opium, Ether, etc., Intellection, 

[ Emotional Influences. 
(b; — Spinal j Strychnia, Brucia, Quinia, Cantharides, Exercise, 
excitants. I (active and passive). 

A. — CEREBRAL EXCITANTS. 

It is very probable that alcohol acts upon the tissue of the 
brain and superior motor centres, as well as upon the circula- 
tion. I have already referred to the dosing of alcoholic drinks, 
and would only add that for the present purpose small quantities 
often suffice. In order to secure uniformity in the dosing of 
alcoholic stimulants, I should be in favor of using diluted alcohol 
instead of wines or brandy or whiskey. The only obstacles to 
the adoption of this practice are the prejudice existing against 
alcohol, and the fact that some stomachs bear wines and beer 
better than spirit. 

Cannabis indica- has been used in cases of melancholia and 
acute dementia, and in various neuralgic states. 

Its specific effect is to excite the imagination. A sort of 



GENERAL THERAPEUTICS OF THE NERVOUS SYSTEM. 147 

delirium is produced which, in most cases, is not accompanied 
by absolute unconsciousness, although the patient has the most 
extraordinary fancies, hallucinations, and delusions. It is this 
power of stimulating the imagination which has placed it among 
the remedies to be administered in apathetic cases. The 
success of the remedy, however, has not quite equalled the 
anticipations of theory. 

In cases of cerebro-spinal mal-nutrition (migraine, etc.) its 
influence is beneficial. 

Belladonna and opium are both stimulating to the brain when 
given in small doses, increasing intellection and producing 
hallucinations. When given in large doses they produce, besides, 
an after-effect of depression. 

It is only upon some few individuals that this peculiar effect 
of belladonna is manifested ; and many patients can take this 
remedy for a long time without complaining of any hallucinations 
or excitation of the imagination. 

One of the dangers of administering opium is the temptation 
to continued indulgence in the use of the remedy for the sake 
of the intoxication which it produces. I would ask you always 
to bear this danger in mind, and to consider the responsibility 
attaching to the giving of opium as not ended until you are 
satisfied that your patient no longer uses the medicine. After 
treating a neuralgia, or other painful affection, with opium 
internally, or with hypodermic injections, you are to withdraw 
the narcotic very gradually — to wean your patient, as it were. 
I cannot conceive of a much greater cause of sorrow for a 
medical man than to have been the cause of the enslaving of a 
human being by the opium habit. 

Ether produces intoxication, which is often very violent, when 
given by inhalation for purposes of anaesthesia. It is not 
ordinarily employed as a cerebral excitant. 

Emotional excitement is not sufficiently employed as a means 
for affecting the nervous centres. It is seldom applicable where 
organic disease is present, but is more especially indicated 
where the mind is absorbed in contemplation of delusions, and 
in hypochondriacal and hysterical cases. 

Cases of hysterical paralysis have been cured by an alarm of 
fire, or some other immediate danger. The pleasurable emo- 
tion of hope is very powerful, and its use makes possible the 
success of various quackish methods. In legitimate practice we 



148 GENERAL THERAPEUTICS OF THE NERVOUS SYSTEM. 

should, I think, make greater use (within the bounds of truth- 
fulness) of the potent emotions of hope and faith. 

Many cases of melancholia have been benefited in a remark- 
able manner by getting them interested in some matter, either 
of love, or affection, or emulation. There are patients who have 
a certain amount of dementia, produced by the presence of some 
convulsive disease, such as epilepsy, chorea, etc. In these cases 
intellectual exercise is to be recommended and insisted upon ; 
some intellectual excitement should be daily enforced. 

B. — SPINAL EXCITANTS. 

Nux-vomica, strychnia, and brucia are medicines which affect 
in an almost specific manner the motor parts of the spinal axis, 
stimulating it primarily. The result of over-doses of these 
remedies is spasm of muscles supplied by spinal nerves. In 
small doses these drugs act upon the same parts slowly, and 
improve their nutrition. The indication for the use of strychnia, 
etc., is the existence of simple exhaustion of the nervous centres, 
of spasm due to weakness and anaemia, of paralysis (inhibitory 
or reflex) not due to inflammation of the spinal centre. 

We also make use of these remedies in some cases of func- 
tional nervous disorders. They are beneficial in cases of 
chorea and epilepsy, the morbid states grouped together under 
the name of " spinal irritation." In many of these cases the 
remedy (strychnia) should be given in the manner long ago 
pointed out by Brown-Sequard, that is, in doses necessary to 
obtain its physiological effects. 

Bearing in mind that females are much more susceptible to 
the influence of these drugs than males, you should commence 
the giving of strychnia by doses of .0015 or .002, increasing 
rapidly to .004 or .005 three times a day for adults. There 
is not the same ratio of susceptibility to the influence of this 
remedy, with regard to age, as is seen in connection with opium 
and some other remedies, children bearing large doses well. 
Nux-vomica may be administered in .015 or .02 doses thrice 
a day, and the doses may be progressively increased. 

It is better to use strychnia in solution. If given in pill, you 
will run the risk of the drug not having been carefully divided 
in the preparation of the pills ; and the additional danger, which 
is much more likely to happen, that the pills will not be dis- 



GENERAL THERAPEUTICS OF THE NERVOUS SYSTEM. 149 

solved in the alimentary canal until an accumulation of them 
has taken place, which will develop results most undesirable. 
The necessity of using an acid to properly effect a solution of 
strychnia permits us to use diluted phosphoric acid, which is 
itself a serviceable remedy in the treatment of nervous affec- 
tions ; or we may use the various acid phosphates which are 
now offered to us in elegant preparations by druggists. 

In cases of paralysis, strychnia may be used hypodermically, 
with benefit, .0015 to .006 being injected once a day, or once 
every other day. For this purpose I would recommend Bar- 
well's solution at half strength, one drop of which contains 
about .001 of strychnia. 

Quinia sometimes acts in a manner which entitles it to a place 
in this class of remedies. 

There has been considerable doubt as to whether quinia 
affects the nervous system at all. There are, however, good 
reasons for believing that the phenomena of intermittent fever 
are of spinal origin. Quinia cures all forms of this disease 
almost with certainty. Another reason for believing that quinia 
affects the nervous centres is the fact that its administration 
aggravates spinal disease. According to Brown-St-quard, it acts 
as a poison to epileptics, and this effect will allow of only one 
explanation, namely, that the motor centres concerned in the 
production of the paroxysm are excited and rendered more sus- 
ceptible by this remedy. Lastly, we have the general tonic 
effects of quinia, which cannot be denied. 

Quinia will also stimulate the cerebrum, as is shown by the 
fact that intellectual exertion is more easy and free after its use. 
Dr. W. H. Draper, of this city, has given small doses of the 
medicine to two well-known clergymen with the result of restor- 
ing their power of extemporaneous speaking. 

Cantharides excites the spinal cord, and seems to act more 
particularly upon its lower portion, manifesting its action by 
the development of symptoms especially connected with the 
genito-urinary apparatus. It is useful in cases of bladder pare- 
sis, of impotency, or simple genital inertia. 

Exercise, both active and passive, is indicated in conditions 
of paralysis or paresis, or in simple spinal debility. Much of 
the passive exercise we make use of is obtained by means of 
electricity, which will be separately considered. Exercise 
should never be pushed to exhaustion ; and I would have you 



150 GENERAL THERAPEUTICS OF THE NERVOUS SYSTEM. 

bear in mind that exertion more easily produces exhaustion in 
the subjects of nervous diseases, and in the insane especially. 

Class B. 

SUB-CLASS II. 

Depressants and Anesthetics. 

C Cold, bromides of potassium and calcium, 
(a) — Cerebral depressants. 1 opium, hydrate of chloral, food, etc., chloro- 

( form, ether, etc. 
(b) — Spinal depressants. j Conium, bromide of potassium, cold and 

\ food. 

(a) Cold is to be employed in the same manner as when we 
wish to produce an anaemic condition of the brain. The inclina- 
tion to sleep experienced by persons exposed to severe cold, 
such as encountered in the Arctic regions, is an illustration of 
the effect which cold can produce upon the nervous system. 

The India-rubber bag sometimes employed in making appli- 
cations of ice diminishes the intensity of cold applied, and is 
inferior to the bladder ordinarily employed (vide supra). 

Bromide of potassium has usually been spoken of as acting 
through the blood-vessels, and causing their contraction and con- 
sequently anaemia of the parts they supply. Dr. "W. A. Ham- 
mond and many others speak of the remedy as acting in this 
manner. 

There has been some doubt expressed as to whether bromide 
of potassium is true hypnotic. 

At present, perhaps, this is to be regarded as an unsettled 
question. For my own part, judging from my own experience 
and the testimony of others regarding bromide of potassium, I 
have been led to conclude that, when given in sufficient doses, it 
acts very powerfully as a cerebral depressant. In health, I admit, 
that no narcotic effects are obtained from a few doses of the 
medicine, but in cases of cerebral irritation, and insomnia from a 
variety of causes, its action is sure and immediate. In delirium 
tremens, for example, in such cases as are not complicated by 
degenerative liver and kidney disease, in the so-called sthenic 
cases, bromide of potassium given in doses of 4. or more every 
hour, until 12. or 16. have been taken, will, conjointly with semi- 
darkness and quiet, cut the attack short by producing sleep. In 



GENERAL THERAPEUTICS OF THE NERVOUS SYSTEM. 151 

1866-67, while House Physician to the New York Hospital, I had 
the opportunity of thus treating a series of cases of this disease 
with very satisfactory result. I say this while perfectly aware 
that several medicines seem to shorten the duration of delirium 
tremens, and that it is, under certain conditions, a self-limited 
disease. 

In certain forms of insomnia seen in connection with fevers, 
the bromide of potassium may fail to produce sleep, because (?) 
of the continued influence of a blood-poison in keeping up the 
morbid state. 

In the insomnia and delirium of pneumonia I have also seen 
speedy relief procured by 2.4 or 4. doses of bromide of potassium. 
In the simpler (?) conditions of sleeplessness caused by anxiety, 
over-exercise of the brain functions, emotional disturbance, this 
remedy usually acts w^ell. Perhaps the most convincing proof 
of the action of bromide of potassium upon the cerebrum is to 
be had from observing the effects of the long-continued use of 
large doses of the remedy. A condition called " bromism" is set 
up, characterized by" stupor, deficient memory, aphasiform speech, 
tottering gait, loss of facial expression, salivation, mucous irrita- 
tion, papular skin disease, etc. Although we see this result more 
often in the course of the treatment of epilepsy, yet it may be 
developed in persons not having this disease. The mental state 
of brominized persons is not unlike that of patients with de- 
mentia. 

Hydrate of chloral is, in my opinion, the best medicine that 
can be employed for producing sleep. It does not intoxicate, or 
disturb the digestive organs, as opium does. "When chloral 
succeeds — and it almost invariably does succeed — it produces a 
calm sleep, not followed by any special disturbance of the 
system. 

I would have you bear in mind that this remedy is a much 
more direct hypnotic than opium, and yet that it does not pos- 
sess the power of preventing the perception of pain. Hence a 
rule to follow is to give chloral in cases of insomnia not con- 
nected with pain. The physicians to insane asylums in Europe 
and in this country have found in chloral an invaluable agent 
for giving rest to patients suffering under mania in any of its 
forms. They have also testified to the very great safety attend- 
ing the use of the medicine, many patients getting large doses 
of it nightly for months, and years. Chloral may also be used 



152 GENERAL THERAPEUTICS OF THE NERVOUS SYSTEM. 

in cases where (vide supra) bromide of potassium is indicated, 
and the two niav be given together. If you are to choose be- 
tween these two drugs, use bromide of potassium if in addition, 
to the cerebral irritation there exists some physical excitement 
(spinal irritation ) ; chloral in cases of pure cerebral disturbance. 
The theoretical view that bromide of potassium acts by causing 
anaemia of the brain leads to the withholding it in cases of 
cerebral anaemia and malnutrition. This I believe to be an error, 
since in my experience the occasional giving of bromide of potas- 
sium (and chloral hydrate ) in such cases has in no way hindered 
the good effects of restorative medicines. 

The dose of hydrate of chloral may be, for adults, 1. or 
4 In females especially it is well to try a small dose on your 
first trial. A 1.2 gm. dose I believe to be a perfectly safe one 
for a man. The doses of 2.4 and 4. should be used in cases of 
acute mania or severe delirium. 

The conjoint use of bromide of potassium and chloral is very 
satisfactory. Four gms. of bromide of potassium may be ad- 
ministered in the afternoon, followed at bedtime by 1.2 or 2.4 of 
chloral. 

Concerning the use of opium and its constituents in diseases 
of the nervous system I believe that I need say very little. I 
would have you always bear in mind the exceedingly unpleasant 
way in which this remedy affects very many females, producing 
insomnia and, later, vomiting and constipation. For these sus- 
ceptible individuals (a few males must be included) some of the 
liquid compound preparations of opium, McMnnn's elixir, the 
liquor opii comp., may be substituted for morphia or simple 
opium. In a very large number of cases of nervous disease we 
seek to relieve pain by the use of morphia. In such cases it is 
best administered hypodermically, in the form of strong solu- 
tion of the sulphate or acetate or muriate. I must admit that 
my own patients seldom receive any but the sulphate of mor- 
phia injections, in the shape of Magendie's solution (1. to 
30.), .60 of which are equivalent to .02 morph. sulph. I am, 
however, in the habit of adding a little atropia, .0006 or .0008 
to each hypodermic injection, for the purpose of palliating the 
nauseating and constipating effects of the morphia. My solu- 
tion of atropia is composed of atropia .06, distilled water 
20. : .06, containing .0002 atropia. I have employed this com- 
bination since 1867 with great satisfaction. 



GEXEEAL THERAPEUTICS OF THE NEBVOUS SYSTEM. 153 

Food is a depressant, because it remedies the morbid irrita- 
bility produced in the brain in cases of exhaustion, whether from 
hemorrhage or over-work. 

Sometimes the effect of food is very marked indeed. Many 
of you have doubtless experienced a sensation of exhaustion, 
accompanied by headache, perhaps severe, which has been en- 
tirely relieved by taking a good meal. The headache perhaps 
has been made to disappear, even "before the meal was com- 
pleted, and you have felt immediately refreshed, and that with- 
out wine or other alcoholic stimulant. 

In many cases of delirium and mania the effects of the persist- 
ent giving of nutritious food are evidenced by rapid improvement 
and cure. 

b. Spinal Depressants. — Conium is the typical medicine of this 
class, and seems to be the direct antagonist of strychnia. It 
acts by paralyzing the spinal motor centres, from the nucleus of 
the third nerve down. This remedy can be used with benefit in 
spasmodic affections. 

In small doses it produces a paretic condition of the spinal 
axis, indicated by partial ptosis, strabismus, or double vision, 
weakness of the knees ; and the arms may become slightly pa- 
retic. These symptoms appear within an hour after the medi- 
cine has been taken. By the administration of larger doses, 
almost complete akinesis is obtained, which may last for half an 
hour or an hour, but is not dangerous. 

The remedy should be given only once a day, and in many 
cases to the extent of partially paralyzing the patient. 

A reliable preparation is the English suocus conii, which may 
be administered in doses from 8. to 24. cc. once a day. An ecpially 
good form of conium is Squibb' s fluid extract. I usually pre- 
scribe this and give it in doses of 2.5 - 4. cc. Dr. John Harley, 
of London, has done much to give us a clear notion of the action 
of this remedy, and he has found it useful in chorea, epilepsy 
and other spasmodic diseases ; he points out the necessity of 
obtaining the physiological effects of this and other drugs when 
we wish really to do good in affections of the nervous system, 
In epilepsy I have employed the fluid extract of conium in com- 
bination with bromide of potassium with good results. 

Bromide of potassium also acts directly upon the spinal cord 
as a depressant. It lowers the activity of the motor tract (though 
in a lesser degree than coniumi and diminishes reflex excitabil- 



154 GENERAL THERAPEUTICS OF THE NERVOUS SYSTEM. 

ity. Its use is consequently indicated in all affections in which 
reflex action is abnormally great, and in many such we obtain im- 
mediate and good results from its administration. In various 
forms of convulsions, the eclamptic attacks of children, of preg- 
nant and parturient women, bromide of potassium does good. 
Morbid excitement of the lumbar part of the spinal cord, as 
evidenced by nymphomania and satyriasis, is often relieved by 
this drug. Some forms of vomiting (in pregnancy, after inhala- 
tion of ether, etc.), spasmodic states of various sphincters, are 
also cured by it. It is in the treatment of the great neurosis epi- 
lepsy that this medicine is the most employed, and it is concern- 
ing its usefulness in this affection that great discussions have 
occurred. The use of it in epilepsy was begun by several physi- 
cians about the same time, but Drs. Brown-Sequard and Laycock 
were the first to call attention to it. The generally received 
opinion is that it is the medicine which possesses more power 
than any other over epilepsy ; that in the majority of cases the 
frequency and severity of the seizures are very much diminished 
while the medicine is being taken (the symptoms soon reappear- 
ing if it be discontinued) ; and that a case here and there may 
be cured by its use. In hospitals with large numbers of epileptic 
patients the effects of giving and withholding the bromide are 
very strikingly in favor of the utility of the drug. For my part 
I wholly accept this as a correct estimate. 

There are a few general rules to be observed in the treatment 
of epilepsy by bromide of potassium. 

In the first place enough bromide of potassium (and other 
bromides if you please) should be given to reduce the reflex func- 
tion and keep it below the normal standard. A test of the suffi- 
cient action of the medicine lies in the reaction of the palate and 
fauces to irritation ; a diminution or abolition of the well-known 
reflex movements of these parts indicating diminution of the 
reflex excitability. Another general rule is to give more of the 
medicine at night than in the day-time ; a direction of great 
value, for which we are indebted to Dr. Brown-Sequard. We 
usually give three day doses, and a dose in the evening twice or 
thrice the size of the day dose. A third and most important 
rule is to administer the salt in a perfectly continuous way 
for months and years. Dr. Brown-Sequard has known patients 
remain without seizures for two years while taking his prescrip- 
tion for mixed bromides, having a return of convulsive seizures 



GENERAL THERAPEUTICS OF THE XEETOUS SYSTEM. 155 

in a short time after ceasing the medication. I have seen similar 
though less striking results. 

There are a few epileptics who cannot tolerate the bromides ; 
who become easily " brominized," and whose attacks are made 
worse by these drugs. These paradoxical patients are very 
rare, I believe. While recognizing the great value of Brown- 
Sequard's compound bromide solution I more commonly employ 
a simple solution of bromide of potassium, giving .30 three times 
a day, and 1. or 1.20 at bedtime, at first in adults. Children 
require relatively very large doses of the bromides, and, contrary 
to what is sometimes taught, I see in anaemia no counter-indica- 
tion to the use of the remedy, nor do I believe that any law can 
be laid down for the giving or not giving of it, from observations 
wpon the retinal circulation. Such a view is based only upon 
belief in the more than doubtful physiological theory that cere- 
bral hyperemia and anaemia are usually prime factors in the 
pathological state called epileptic. 

Class C. 

Tonics and Restoratives. 

By restoratives I understand, with Headland, those remedies 
which restore to the system an element, diminished by a disease, 
cr whose diminution causes a disease. A few of this class are 
especially useful in diseases of the nervous system, two chiefly, 
— phosphorus and fats. 

I would not be willing to admit that there is any defined morbid 
state of the nervous system which can be shown to depend upon a 
diminution of the phosphorus, which is so important an ingre- 
dient of nerve tissue, yet I am the first to recognize that in some 
nervous diseases much phosphorus is excreted, and that in very 
many of them much benefit, even to a cure, is obtained by giving 
phosphorus. In practice the various phosphates, the acid phos- 
phates, the hypophosphites, etc., if they do good, do so very 
slowly, and are hardly to be used in the treatment of serious 
cases, except as adjuvants. Phosphorus itself may be adminis- 
tered in the form of the officinal oil, or in the non-officinal solu- 
tions (Thompson's), and as phosphide of zinc. The dose of 
phosphorus ranges from .0016 to .005; that of zinc phosphide 
from .01 to .03. In administering this powerful remedy, 



156 GENERAL THERAPEUTICS OF THE NERVOUS SYSTEM. 

please bear in mind that some organizations are very susceptible 
to its toxic influence. In cerebral mal-nutrition, in neuralgia, 
in "spinal irritation," in hysteria, and in varieties of paralysis, 
this drug is of the highest value. 

Fatty food and cod-liver oil are indicated in the conditions 
which demand phosphorus. 

Among the tonics the chief are strychnia, arsenic, zinc, iron, 
quinia and cold, Cold should, for its tonic effect, be applied 
only for a short period of time. This may be done by sponging, 
the shower-bath, cold compresses, the cold sheet and sea-bathing. 

A corresponding reaction follows, which consists in hyper- 
emia and improved nutrition. (Vide infra, counter-irritants.) 

We are unable exactly to explain why strychnia, or arsenic, or 
zinc, should benefit the general nutrition, but daily experience 
teaches that these remedies are invaluable in many morbid states 
of the nervous system. 

Strychnia, in cases of irritability, of hysteria, spinal irritation, 
and in some palsies, may be given in small doses for long periods 
of time ; doses of .0016 or .002. The action of arsenic is often 
marvellous in chorea, and very satisfactory in other nervous 
diseases. Fowler's solution is the arsenical preparation most 
commonly employed, and in chorea it should be dealt out with 
no sparing hand ; doses of from .30 to as high as 1.2 cc. being 
well borne. The oxide and lactate of zinc have been much used 
in states of exhaustion of the nervous system, after sexual excess, 
or in chronic alcoholism, and in epilepsy. In the nervous states 
caused by alcohol the zinc oxide proves almost as satisfactory as 
arsenic in chorea. I have usually employed it in combination 
with extract of nux-vomica. Since the introduction of potassium 
bromide into general use, the zinc treatment of epilepsy has 
fallen into (perhaps unmerited) disuse. 

Quinia, in moderate doses, would seem to act as a tonic. It 
is possible that it does so by causing more food to be taken and 
digested, yet from the immediate improvement in well-being and 
in cerebral activity which many experience while taking it, I am 
inclined to the opinion that this remedy does exert a direct 
effect (restorative ?) upon the nervous centres. 

Iron I have not spoken of, because it does not especially affect 
the nervous system. It improves the condition of the blood, 
and, by so doing, cures morbid states of the nervous system 
(neuralgia), which depend upon anaemia or chlorosis. 



GENERAL THERAPEUTICS OF THE NERVOUS SYSTEM. 157 

Perhaps it were well that I should here speak of two so-called 
specific modes of medication, very useful in nervous diseases, and 
which would not otherwise enter the classification offered you. 
I refer to the treatment of constitutional syphilis, which often 
gives rise to morbid states of the nervous system. Nearly all of 
these morbid states are a part and parcel of the third (tertiary) 
stage of syphilis, depending upon affections of fibrous tissues of 
bones, of blood-vessels, and upon the presence of gummata in 
the nervous centres. I would only speak of one point in con- 
nection with this subject, and that is the necessity of using the 
iodide of potassium in really effectual doses, giving from 4. to 
24 a day until improvement takes place. You will be sur- 
prised to see how a patient with tertiary syphilis will gain while 
taking 16. of iodide in the twenty-four hours, after having re- 
sisted smaller doses. No unpleasant symptoms attend the 
taking of large doses, provided that restoratives and good food 
be also given. 

The other specific medication is the treatment of malaria in 
its original form by quinia. Malarial neuralgia is a well-known 
and an obstinate affection. It may be cured by quinia in the 
usual way ; but a much more rapid removal of the disease is 
obtained by using the quinia in the shape of hypodermic injec- 
tions over the affected nerve. We then obtain the specific effect 
of quinia on the nervous centre and counter-irritation on the 
nerve. Nearly seven years ago * I published the results of my 
experience with this medication in the New York Hospital, giv- 
ing full details of the practice. As a general rule, in nervous 
disorders dependent upon malaria, do not err by giving too little 
quinia. 

Class T>. 

Counter-irritants. 

By counter-irritation is understood a localized irritation, 
which modifies the nutrition or mode of activity of another part 
than that irritated, either just beneath it, or at a distance from 
it. Counter-irritants almost always act through the spinal cord, 
and their mode of action is exemplified by a morbid process that 
takes place as a consequence of severe burns. If a limb or part 

* On the Subcutaneous Use of Sulphate of Quinia in Cases of Malarial Neural- 
gia. New York Medical Journal, 1867, p. 402. 



158 GENERAL THERAPEUTICS OF THE NERVOUS SYSTEM. 

of tlie body be scalded or charred, the patient is not in danger 
merely because of the shock of the injury, or of the exhausting 
discharge accompanying the healing of the burn, or of the 
pyaemia which may take place during the continuance of this 
suppuration, but he is also likely to suffer from certain visceral 
complications which occur in parts bearing a definite relation to 
the burn. Brown-Sequard demonstrated many years ago that 
by cutting across the spinal cord, above the origin of nerves 
going to the burnt part, no visceral lesions occurred ; thus prov- 
ing that these lesions were set up by a morbid state of the spinal 
cord, produced by the burn. The burn corresponds to our 
counter-irritation, and the altered nutrition of the viscera to the 
distant effect produced. In the one case a morbid process is 
induced ; in the other a beneficial change, not yet understood by 
us, is determined. 

The alternate application of cold and heat does much to im- 
prove the nutrition of paralyzed parts, and is used for many 
special purposes. 

Brown-Sequard has recommended the use of these means to 
prevent the formation of bed-sores, and to heal those which 
may be already formed. 

The method consists in applying an ice or snow-poultice over 
the part for ^lyq or ten minutes, following this by the immediate 
application of a hot poultice. This should be done once a day 
over the parts threatened with the formation of bed-sores. 

When the same thing is done twice a day to sores already 
formed, as a rule, sloughs come away, circulation is improved, 
and granulations will soon spring up. I have seen huge bed- 
sores healing under this treatment while the patient was failing. 

The actual cautery is a means of the utmost value in the 
treatment of nervous affections. It is one, however, which has 
fallen into very great disrepute in consequence of the manner in 
which it was formerly employed. A burn sufficient to produce 
suppuration is not necessary, surface-irritation being what we 
seek to produce. 

The theoretical view that surface -irritation is most useful, 
has, like several others brought forward in this lecture, a true 
physiological basis. It rests upon the well-known law that the 
terminal nervous twigs, and their special terminal bodies, are 
more irritable than nerve trunks. t 

Brown-Sequard has revived the use of the actual cautery; and 



GENERAL THERAPEUTICS OF THE NERVOUS SYSTEM. 159 

by means of his form of cautery we are enabled to produce 
much skin irritation, with little pain to the patient, and no sub- 
sequent annoyance from sore surfaces. 

The cauterizing iron which he employs is tipped with plat- 
inum. The platinum never gets rough by ordinary heat, as 
does iron, and there is, consequently, a smooth surface to come 
in contact with the skin every time the cautery is used. 

The white-heat is necessary in using the actual cautery, be-- 
cause it produces the maximum degree of irritation to the nerve, 
with a minimum of pain. 

The cautery thus heated (in a coal fire) should be rapidly 
drawn over the part selected, four or more strokes, of from one 
to six inches in length, being made. This can be done in a very 
few seconds, and in many cases no real pain is experienced by the 
patient. The strokes remain as reddish-brown welts, which are 
quickly surrounded by a zone of hyperemia, which is sometimes 
immense. A moderate degree of burning pain is felt for twenty 
minutes or two hours after the application. Sores never result 
from the burning, and not once in twenty strokes have I ever 
seen blisters arise. The epidermis is cast off dry in a few days, 
leaving a brownish stain which passes off wholly in a short time. 
The cautery can be used upon the face with perfect safety. I 
have made use of this most valuable means in women, and 
children thirteen years old, without anaesthetics. The disagree- 
able ideas connected with the words " burning " and " cautery," 
in the minds of physicians and of patients, are the barrier to the 
more general use of the platinum cautery. 

Setons have so much gone out of fashion that I need hardly 
stop to enter a protest against their use. It is very doubtful if 
a suppurating sore produces more irritation than the cautery or 
blisters, and there are grave objections to using setons. 
* Blisters are invaluable means of producing counter-irritation. 
Let me ask you to use them in such a way as not to produce 
suppuration ; repeat the blisters and heal the blebs as soon as 
possible. Great good is often obtained from a series of small 
blisters. 

Dry cupping is beneficial in many spinal affections. The 
number of cups applied should be large — from ten to twenty. 
It is not necessary to use the cups immediately over the seat of 
the disease. Ten cups may be applied upon the back, and ten 
in front, with the same benefit as if all were applied behind. 



160 GENERAL THERAPEUTICS OF THE NERVOUS SYSTEM. 

It is a matter of doubt whether wet cups act better than, or in 
a different manner from, the dry. The degree of skin irritation 
produced by the process of wet cupping is certainly very much 
greater than in that of dry cupping ; and it cannot be positively 
denied that the loss of blood is useful. In various inflammatory 
affections of the cerebral and spinal meninges, and in some 
functional disorders, wet cups are still used. 

Sulphur baths do good by the irritation they produce upon 
the surface, rather than from any effect of the sulphur upon the 
system generally. These baths may be employed liquid or in 
the shape of vapor. For liquid sulphur baths, the sulphuret of 
potassium is dissolved in water, and the patient soaks himself 
awhile in the solution. A better application is obtained by 
vaporizing sulphur in a chamber into which steam is admitted, the 
patient's head being kept out of the bath, of course. A stay of 
ten or twenty minutes in this atmosphere produces a great deal 
of cutaneous irritation, which, in time, leads to a decided des- 
quamation. Some of the natural sulphur spring waters are 
also used for bathing purposes, but are much less effectual. In 
spinal diseases, particularly posterior spinal sclerosis (locomotor 
ataxia), series of such baths have done great good. They are 
also useful in lead poisoning. Many medicated baths likewise 
act by producing extensive irritation of the skin. 

Class E. 

Electricity. 

We employ all three forms of electricity in medicine, Frank- 
linism or statical electricity, Galvanism (or Yoltaic electricity), 
and Faradism or induction electricity. 

Any one of these forms may be used in the treatment of dis- 
eases of the nervous system in a rational or an empirical way. 

The rational applications of electricity are to produce muscu- 
lar contraction (passive exercises) and to affect the nerves of 
sensation (irritation, sedation.) 

What I may call the empirical use of electricity is when we 
attempt, by means of it, to modify the mode of activity of deeply 
placed organs, such as the brain, spinal cord, and the ganglia of 
the sympathetic. 

It would be out of place for me to attempt, in a few words, to 
speak of the special application of electricity. A great deal has 



GENERAL THERAPEUTICS OF THE NERVOUS SYSTEM. 161 

been written about this matter in the last few years, and I am 
glad to say that there are a few small books on the subject which 
I would urge you to study. I need only say that within certain 
limits, corresponding with our physiological knowledge, I have 
the greatest faith in the power of Faradism and Galvanism as 
remedial agents, and that I use them a good deal. 

Class F. 

Hygienic Means, etc. 

The cases of nervous disease which are strictly speaking active, 
due to hyperemia or overaction of the nervous centres, I regard 
as being exceedingly rare. Consequently, I regard the immense 
majority of cases as requiring a supporting diet and such hygiene 
as shall tend to improve nutrition. 

There are very many points to be considered in this connec- 
tion. 

In the first place, many paralytics suffer from slow digestion 
and constipation. The diet of such patients should consist of 
such articles of food as leave little detritus, as meats, fish, eggs, 
milk and fats. Vegetables and starchy or sweet articles should 
be allowed sparingly. 

In the second place, the bladder in many cases (spinal palsies) 
requires to be emptied by means of the catheter. In such cases 
you cannot exercise too much gentleness and care in introducing 
the instrument, for fear of setting up cystitis, or of aggravating 
one already present. 

Thirdly : In many spinal cases there is immensely exaggerated 
reflex activity of the spinal centres ; spinal epilepsy is set up by 
the contact of the bed-clothes, your hand, etc., with the palsied 
limbs, and an overloaded bowel brings about attacks which 
seem spontaneous. By strict orders to the nurse and by the 
help of mechanical contrivance you can reduce these spasms to 
a minimum. If one occur, recollect that you can stop it by for- 
cibly flexing one or both great toes, as indicated by Brown- 
Sequard. 

Fourthly : I would ask you always to bear in miud that bed- 
ridden paralytics are peculiarly liable to fatal attacks of bron- 
chitis, broncho-pneumonia, and pneumonic phthisis. Remem- 
bering this, you will give directions to obviate all that which 
might expose your patients to such chest complications. 
11 



162 GENERAL THERAPEUTICS OF THE NERVOUS SYSTEM. 

Fifthly : Inasmuch as bed-sores are likely to occur among the 
complications of nervous diseases, a few words may be added 
to what has already been said concerning their prophylaxis. 

It is important to make every piece of clothing beneath the 
patient smooth. Consequently, a pretty hard mattress or water- 
bed is the best for him to lie upon. Special care is to be taken 
that the under sheet does not get wrinkled and drawn into folds ; 
its ends may be fastened down by tapes. The shirt worn by the 
patient should be kept smooth under him, and perfect cleanli- 
ness must be enforced. Special attention to these apparently 
small matters will in most cases be sufficient to prevent the for- 
mation of eschars. 

In case a bed-sore has formed, the best course to pursue is to 
clean away all necrosed skin and connective tissue (tow-like 
shreds) by means of forceps and scissors, and then to use the 
ice and poultice treatment as above detailed. When healthy 
granulations spring up, ice poultices are still useful once or 
twice a day, to be succeeded by ointments, or adhesive plaster 
strapping. 

Sixthly : In the matter of coffee, alcoholic drinks and tobacco. 
You will hear physicians asking their patients to give up the 
use of these articles simply because they have a disease of the 
nervous system. I am afraid, gentlemen, that this is very illogi- 
cal. For my own part I do not proscribe these luxuries unless 
there is evidence that their use has had something to do with 
the development of the morbid state. Usually I do not at all 
interfere with the use of coffee, and ask that a less quantity of 
alcoholic drinks and tobacco should be used. The worry and 
nervousness consequent upon the giving up of an established 
habit is worse for the patient, in my opinion, than the moderate 
use of the above-named articles. 

Let me close this rather fragmentary lecture, by calling your 
attention to something which is not wholly extra-medical. I 
allude to the care of your patients' spirits — their emotions and 
fancies if you will. Never let alarm be one of your medicaments. 
If necessary, in order to bring about the reform of bad habits, 
lay the picture of consequences before your patient truthfully, 
but not in the language of exaggeration. Even in hysterical 
cases you need not be so frank as to hurt your patient's feeling : 
it will often do if her relatives know precisely what you think of 
the value of the symptoms. In cases of mental disorder, pray do 



GENERAL THERAPEUTICS OF THE NERVOUS SYSTEM. 163 

not forget that even very maniacal or melancholic patients attend 
to and remember all your words and actions, and will treasure 
any kind and careful behavior of yours as well as bitterly recall 
any unkind or hasty phrases and acts. As a general therapeutic 
rule, I would have you be as anxious to avoid wounding the 
sensibilities of your poor or wealthy patients as of injuring their 
tissues. 



AN OUTLINE OF THE PHYSIOLOGY OF THE NEKY- 
OUS SYSTEM.* 

Gentlemen : — In thinking of a subject to present to you in an 
introductory lecture, it occurred to me that a good one would be 
a sketch, very much condensed, of the anatomy and physiology 
of the central nervous system, to serve as a basis upon which 
we can, during the winter, build up a knowledge of diseases of 
the brain. I shall be very brief upon the individual heads of 
the lecture, wasting no time upon matters which are not capable 
of bearing a logical relation to pathology. 

Before entering upon the subject proper, I wish to say a few 
words, intended to give you a clearer idea of the relation of 
medical to general knowledge. I mean to warn you against the 
error which it must be said some of the books in your hands 
tend to strengthen and perpetuate, viz., the separation of phys- 
iology from pathology, and the confounding of the latter with 
pathological anatomy. If we look at the matter from an extra- 
medical or philosophical point of view, we are led to classify 
our knowledge of the animal body into two categories : statical 
and dynamical knowledge. In other words, we study the 
animal organism and its parts in a state of rest, and in a state of 
activity; we observe the form and constitution of parts, and 
determine their properties and functions. 

The study of the human body and its parts in a state of rest 
is called anatomy, in the broad sense of the word, making it to 
include chemical and microscopical analysis. Anatomy is 
spoken of as normal (with many subdivisions) when it describes 
the healthy parts and tissues ; as pathological or morbid when 
it treats of the changes produced in tissues and parts by disease. 

Our dynamical knowledge, embracing the study of the prop- 
erties and functions of the parts we have anatomically analyzed, 
is called physiology; and this must, like anatomy, be separated 

* A lecture introductory to clinics upon Diseases of the Nervous System, de- 
livered at the College of Physicians and Surgeons, New York, on Saturday, 
October 3d, 1874. Reprinted from the JS T . Y. Medical Record of Dec, 1874, 
vol. ix. 



PHYSIOLOGY OF THE NERVOUS SYSTEM. 165 

into two great subdivisions — physiology, strictly speaking, and 
pathological (or morbid) physiology or pathology. The activities 
we observe in abnormal (pathological) states are not different in 
kind from those which pervade the organism in health; nor are 
the laws of derivation and utilization of these activities different 
from the laws which operate in the normal body. By close 
analysis we find that in diseased states, as in health, physical 
and chemical laws govern the frame, and that essentially the 
results of their operation are the same. It can, I believe, be 
demonstrated with all but mathematical exactness, that the great 
law of conservation and correlation of force is supreme in the 
disordered and in the perfect animal organism. There is and 
can be no entity of disease, no demon. Even therapeutics can 
be brought into accord with this conception cf medical knowl- 
edge ; for our medicines and remedial agents are only means by 
which we aim to act upon the human body in such a way as to 
modify the shape or constitution of its parts, and to alter the 
mode of activity of its tissues and organs. And although the 
modus operandi of most medicines is obscure as yet, I think it 
not rash to say that medicinal agents do not act in any super- 
natural or occult way, but by the laws of physics and chemistry. 

The study of the physiologist, and of the pathologist as well, 
begins with the nutrition of simple tissues, single cells, or even 
masses of protoplasm ; and upon such a study, as a basis, there 
is built up the more complicated and elaborated knowledge of the 
activities of the human body which the practical physician needs 
so much at the bedside. 

A consideration of what I have said will, I trust, lead you to 
admit two propositions : first, that we physicians are in reality 
naturalists, studying what we call disease by natural and 
scientific methods ; second, that the most excellent physician must 
be the man who (contrary to a vulgar prejudice), together with 
a practical turn of mind and a sympathetic nature, has the 
greatest amount of scientific knowledge at his command. 

I have thus apparently gone out of my way in order to help 
you in viewirig this lecture as a logical whole, an imperfect at- 
tempt to give you a guiding plan in your studies of diseases of 
the nervous system. 

The subject of the lecture is naturally divisible into three 
parts. 

1st. A study of the elementary parts of the central nervous 



166 PHYSIOLOGY OF THE NERVOUS SYSTEM. 

system — their anatomical attributes and physiological proper- 
ties. 

2d. A study of the organs and apparatuses in the central nerv- 
ous system, and their functions. 

3d. A summary of the chief modifications of the properties 
and functions which constitute the symptomatology of disease. 

1. The part comprising the nervous centres may be classified 
as follows : 

A. Bindweb (neuroglia). 

B. Blood-vessels and lymphatic spaces. 

c. Nerve fibres \ ^ -,• •' 

( amyelmic. 

d. Nerve cells (ganglion cells). 

A. The bindweb, gentlemen, is the framework in which lie the 
strictly nervous elements of the nervous system ; it incloses and 
supports nerve fibres, nerve cells, and blood-vessels. Its histo- 
logical composition is that of a fibro-connective tissue, according 
to the latest observations. In it we meet with bundles of con- 
nective-tissue fibres, with exceedingly delicate fibrillse of fibrous 
tissue, and with more or less altered cells lying often at the 
point of meeting of the fibrillae. The fibrous fibrillse are more 
immediately in relation with the nerve fibres and cells, while the 
connective tissue, constituting the septa and the cortical layer 
of the spinal cord, are united at the periphery with the pia ma- 
ter, or innermost membrane of the three surrounding the brain 
and cord. The bindwebs of the brain and spinal cord are simi- 
lar in kind, but the cerebral fibro-connective tissue is much the 
more delicate, The statements that there is a " granular matter " 
in the neuroglia, or that it is a sponge-like tissue, I believe from 
personal observations to be based upon inexact examinations. 
At any rate, it suffices for our purpose to know the bindweb as 
a form of connective tissue, containing nuclei which may be the 
starting-point of proliferation changes tending to truly patholog- 
ical, or to reparative changes. 

B. The blood-vessels of the nervous centres are Very abundant, 
and are in many respects peculiar. The capillaries are by far 
more numerous in the gray matter of both encephalon and spinal 
cord than in the white substance. The larger vessels all reach 
the nervous organs through the pia mater. The rarity of anas- 
tomoses between the arteries in the cord and brain is a most 



PHYSIOLOGY OF THE NERVOUS SYSTEM. 167 

a 

striking feature, and is closely related with pathological proc- 
esses. The non-capillary vessels are remarkable for the rela- 
tively extreme development of their muscular coat. The greatest 
peculiarity presented by these vessels, however, consists in their 
having an outer sheath, constituting a canal separated from the 
vessel by a small amount of fluid. All the vessels of the cerebro- 
spinal mass are thus inclosed. These so-called perivascular 
canals are made up of very delicate connective (structureless ?) 
tissue, and contain a fluid very analogous to lymph. The peri- 
vascular canals are an extension into the parenchyma of a vast 
system of lymphatic spaces which surround the nervous centres, 
the so-called sub-arachnoid space in the meshes of the pia mater 
around the brain and spinal cord. This arrangement has been 
known for several years ; and we now know, by the recent inves- 
tigations of Kanvier and Axel Key, that the same sub-arachnoid 
or lymphatic space extends outward with every cerebral and 
spinal nerve to its termination. You should imagine the nervous 
system — brain, spinal cord, and their nerves — as floating in lym- 
phoid fluid, contained in a delicate connective-tissue envelope. 
Even in the eye-ball and internal ear these lymph spaces have 
been demonstrated. Wo are only beginning to appreciate the 
bearing of these important anatomical discoveries to patholog- 
ical processes. It has been stated that nerve cells, in the cerebral 
convolutions especially, are surrounded by a similar lymphatic 
space — an extension of the one described — but this is, I am con- 
vinced, an error of interpretation, the space seen having been 
produced by the shrinkage of the cells under certain modes of 
preparation. 

c. Nerve fibres. Several classifications of nerve fibres are in 
use, but the simple one of two classes — myelinic and amyelinic 
— will suffice for us physicians. But the term myelinic nerve 
fibre is meant a complete nerve fibre, one consisting of three 
parts — a central body or axis cylinder, a surrounding mass of 
fatty substance, the myeline, and a structureless enveloping 
sheath (the membrane of Schwann). In some parts of the nerv- 
ous system the last element is absent. The amyelinic fibre is 
simply a naked axis cylinder. You see from these definitions, 
that the essential part of the three is the axis cylinder ; the other 
two, which may be called insulating, are superadded. The 
amyelinic fibres are met with in the gray substance mostly, but 
are also abundant in the sympathetic nerves. "We find myelinic 



168 PHYSIOLOGY OF THE NERVOUS SYSTEM. 

nerve fibres, without the membrane of Schwann, and varying in- 
finitely in size, in the white columns of the spinal cord, and in 
the white substance of the encephalic mass, constituting the 
bulk of these parts. There are also such fibres, though minute 
ones, in the gray substance of the cord and brain. The periph- 
eral parts of the nervous system, all the cerebral and spinal 
nerves, and a part of the sympathetic, are made up of the second 
variety of myelinic fibres — those which have the three parts. 

A peculiarity of nerve fibres is that they extend independently 
of each other, i.e., not anastomosing, from their origin to their 
distribution, from nerve-cells in the central nervous mass to 
peripheral organs ; and this isolation of nerves, together with 
their insulation, explains a physiological attribute to which I 
shall call your attention. I should add that forty years ago it 
was believed that nerve fibres extended from the brain to the 
outer parts of the body, and that the spinal cord was chiefly a 
bundle of nerves. Progress has strongly tended to take this 
supremacy away from the brain, to show us the importance of 
the spinal cord as a centre ; and we now believe that nerve fibres 
once in the spinal cord run only a comparatively short distance 
before uniting with nerve cells. 

D. Nerve cells are the noblest elements of the nervous system — 
those which possess the power of generating force in the modern 
acceptance of the phrase, i.e., the property of evolving nerve 
force out of chemical activity. They are found in greatest num- 
ber in the brain, spinal cord, and sympathetic nervous systems- 
aggregations of them constituting gray matter or ganglia. Nerve 
cells, wherever found, consist of organized matter, call it proto- 
plasm if you will, not inclosed in any cell membrane, sending 
out prolongations or processes of various shapes and lengths, 
containing a globular body called the nucleus, which itself in- 
closes a smaller body termed the nucleolus. These nerve cells 
vary in size, in shape, and in the number of their processes. 
The largest ganglion cells are met with in the anterior gray 
horns of the spinal cord in its lumbar and cervical enlargements. 
In the ox, cells taken from these localities are almost visible to 
the naked eye. In the floor of the fourth ventricle (medulla 
oblongata) and in certain parts of the base of the brain large 
cells are also found. The smallest cells occur in the gray matter 
of the cerebral convolutions, and in parts of the medulla oblon- 
gata. As regards shape, four subdivisions may be recognized : 



PHYSIOLOGY OF THE NERVOUS SYSTEM. 169 

polyhedral, pyramidal, oval, and round. The first are met with 
in the same location as the largest cells ; the pyramidal are 
nearly restricted to the cerebral convolutions ; oval cells are 
found in the median and posterior parts of the gray matter of 
the cord, and in the medulla ; round cells in the sympathetic 
and in the ganglia of the posterior roots of the spinal nerves. 
"With respect to the disposition of their processes, cells are dis- 
tinguished as multipolar, bipolar, and apolar. I do not believe 
in the existence of apolar nerve cells. Under the name of multi- 
polar cells we include a majority of ganglion cells ; those of the 
cerebral cortex exhibiting from three to six processes, the large 
cells of the medulla and spinal cord showing a great many — 
eight, twelve, or more. Bipolar cells are rarely seen in prepara- 
tions from the human nervous centres. The separation of cell 
processes into two classes was an important progress. A multi- 
polar cell sends out one stout, thick process, which extends a 
long distance, not subdividing, ultimately forming, with the 
addition of myeline, a nerve fibre. The same cell also throws 
off an indefinite number of processes of unequal size, which 
rapidly subdivide, growing smaller and smaller. The former is 
the "cylinder axis process ; " the latter are the "protoplasmic 
processes," and their destination is unknown. It has been 
claimed that the number of processes and the size of cells afford 
an indication of their special functions, but that is not believed 
to-day. I should add that the communications between cells 
which you will find figured in books do not exist ; and that the 
communication of nerve fibres with nerve cells has been demon- 
strated, though a very few times. 

These elementary structures, while alive and forming a part 
of the animal body, possess certain physiological properties, 
some common to all, others the special attributes of individual 
parts. The most common of these physiological properties is 
that of being osmotic, i.e., of allowing fluids to pass through 
them. This property is possessed in a very high degree by 
capillary vessels, by arterioles, venules, and the perivascular 
sheaths — the escape of material from them to the tissues, and 
vice versa, being very rapid and free. The bindweb, also, has 
the osmotic property in a high degree, and thus serves as an 
aid to nutrition as well as a mechanical support. Nerve fibres 
and nerve cells are undoubtedly osmotic, but to a much less 
degree. Wherever it exists, this important process is under the 



170 PHYSIOLOGY OF THE NERVOUS SYSTEM. 

same laws ; it is only possible when liquids of different density 
are on either side of the membrane ; its rapidity is increased 
by motion, pressure, heat, and chemical action, all of these being 
found in the living nervous centres. 

Chemical changes of a very complicated sort are going on 
constantly in the cells and nerve fibres of the central nervous 
system, constituting the essence of nutrition. In a state of 
health the acquisition of new material by the tissues is so 
balanced with the separation of effete matter, that, in spite of 
great internal activity, the parts are maintained in a uniform 
(not mathematically equal) condition. We should never forget 
that this chemical action in myriads of parts cannot take place 
without producing other correlative effects, such as nerve force, 
heat, and electric currents. 

Nerve fibres possess certain special physiological properties. 
In the first place, they conduct the impressions they receive, in 
both directions, from the central organs to the periphery and 
vice versa. This conduction is not by any means instantaneous 
or even very rapid, as it takes place in isolated nerve fibres at 
the rate of less than 55 meters per second, whereas the speed 
■of electricity is 428,000,000 meters; that of light, 277,000,000; 
that of sound, 306 ; that of a cannon-ball, 509. In the living 
body the rate of transmission is from 33 to 40 meters. This 
conduction is done, furthermore, in a perfectly isolated way 
by individual nerve fibres ; there is no interference between 
fibres on their way to and from the central organs. Nerve fibres 
are excitable, that is, respond to stimuli — mechanical, chemical, 
and electrical — by motor manifestations or by sensations when 
the motor or sensory filaments are experimented upon. This 
excitability is quite independent of the nervous centres, and is 
inherent to the nerve, as is shown by the fact that a nerve 
continues to react to stimuli for three days after its separation 
from continuity with the nervous centre. 

Nerve cells have properties whose existence we learn in part 
through reasoning by exclusion, after having ascertained the 
properties of nerve fibres, and in part by direct experimentation. 
In the first place, certain nerve cells have the power of furnishing 
force (motor impulse) to nerves and muscles; this is called 
motricity by some authors. Another property of nerve cells is 
sensitivity, that is, the property of transforming impressions 
received from without by and through the sensory nerves into a 



PHYSIOLOGY OF THE NERVOUS SYSTEM. 171 

sensation. That nerve cells possess a power over the nutrition 
of parts non-nervous, we now incline to believe ; but we hardly 
yet dare name and define this property. But nerve cells have, I 
believe, yet one physiological property, viz., that of retaining 
impressions made upon them; a property for which I now 
propose the term retentivity. I have for some time believed 
that nerve cells (and other cells to a degree) do in all parts what 
it is acknowledged they do in the cerebral convolutions — they 
possess memory, or the property of registering or retaining 
impressions. That this is probable is shown by the fatality of 
numerous actions occurring a second time and oftener. The 
occurrence of a sensation will give rise to a flow of ideas asso* 
ciated with the sensation, and this under normal conditions will 
be repeated whenever the sensation is renewed. An action of 
the class called reflex or sensori-motor is, after its first perform- 
ance, fatally repeated whenever the same initial sensory irritation 
occurs. A bolus of mixed foods passing down the alimentary 
canal provokes in a necessary or fatal way the action of various 
muscular, vascular, and glandular organs. The well-known 
experiment of placing a drop of acid near a frog's anus, after 
decapitation, illustrates my view of the possession of memory by 
the nerve-cells of the spinal cord ; for in this experiment the 
hinder legs of the animal are drawn up and moved in an appar- 
ently intelligent manner, in such a way as to remove the irritating 
acid. Three years ago, in spring lectures given here, I explained 
this phenomenon by saying, that the frog having during its life 
often performed this act for the same purpose, its occurrence 
after cerebral death takes place by necessity, because the same 
sensation is transmitted to the spinal cord. Additional proof of 
the correctness of this theory is to be obtained from a study of 
the mode of acquisition and retention of complex co-ordinate 
movements, such as walking, dancing, piano-playing, etc. Mo- 
tricity, sensitivity, and retentivity are therefore the chief special 
physiological properties of nerve cells. 

Let us now, gentlemen, resume our statical, or if you please, 
anatomical study. The various nervous elements which I have 
sketched for you are combined in the living body in such a way 
as to constitute organs and apparatuses. The term organ I 
would apply to such parts as are the seat of performance of 
relatively limited and less important functions, while by appa- 
ratus I understand a combination of organs serving for the 



172 PHYSIOLOGY OF THE NERVOUS SYSTEM. 

evolution of important and comprehensive functions. The spinal 
cord, medulla oblongata, pons Yarolii, cerebellum, and cerebrum 
may be named as the central nervous organs, made up as 
follows : The cerebrum consists of a superficial or cortical layer 
of gray matter, i.e., of tissue made up of nerve cells, and both 
kinds of nerve fibres (myelinic and amyelinic), arranged in a 
somewhat complicated way. This gray matter rests upon the 
white substance composed of myelinic fibres, which extend 
downward and inward to certain basal gray bodies or ganglia, 
the optic thalamus, and the corpus striatum ; or the white 
substance may be described as radiating from these bodies 
toward the peripheral gray matter, which latter is arranged in 
folds called convolutions or gyri. The cerebellum has an analo- 
gous structure, with variations — the corpus dentatum as central 
gray body, and white substance radiating thence to the periph- 
eral convolutions. The pons Varolii is made up of white 
substance on its outer and anterior parts, with masses of gray 
matter within. In the medulla oblongata we find an analogous 
structure, white matter at the periphery and gray matter in the 
centre and posteriorly. The floor of the fourth ventricle contains 
a series of most important ganglia (masses of gray matter). The 
spinal cord has the same structure throughout its length — a 
structure best described upon a transverse section. Such a 
section is seen to consist of symmetrical halves, each containing 
a central gray mass and peripheral white matter. The gray 
matter is divided into anterior and posterior masses, the so- 
called horns, of which the anterior is the larger. The posterior 
horn reaches out to the margin of the organ, but everywhere else 
there is white substance outside of the gray horns. The shape 
of the gray horns and the relative proportion of white^and gray 
substances vary in different parts of the cord, but that does not 
immediately concern us. From the spinal cord, symmetrical on 
either side, are the roots of nerves ; the posterior roots being 
attached to the cord just inside of the posterior horn, the ante- 
rior roots issuing from the anterior mass of white matter. Upon 
the posterior root, just before it conjoins with the anterior root, 
we see a small swelling, which is a mass of gray matter — a 
ganglion. The white peripheral matter is usually subdivided in 
each half of the spinal cord into two parts — the antero-lateral 
columns, and the posterior columns — the dividing line between 
them being the posterior gray horn, where it strikes the periph- 



PHYSIOLOGY OF THE NERVOUS SYSTEM. 173 

ery of the organ. A microscopic central canal runs the entire 
length of the spinal cord, continuous with the large openings 
called the ventricles, in the encephalic masses. Just at the 
junction of the spinal cord and medulla oblongata, in front, is 
seen a limited spot where bundles of white substance cross the 
median line, being myelinic fibres extending from the anterior 
column or pyramid of one side of the medulla to the antero- 
lateral column of the other side of the cord, constituting the 
so-called decussation of the pyramids. 

The encephalic nerves all terminate in parts below the hemi- 
spheres and cerebellum. If I add that histologically and 
morphologically every part beneath the cerebrum, cerebellum, 
and opto-striate bodies belongs to the spinal cord, it will be 
truthful and of great help in our physiological and pathological 
studies. Ever since I began lecturing here, four years ago, I 
have taught this natural division of the nervous centres into the 
spinal axis, cerebellum, and cerebrum. Accepting this classifi- 
cation of the centres, we can also say that with the exception of 
the olfactory, all nerves are spinal, which philosophically is 
perfectly true. 

I will now call your attention to certain great functions of the 
central nervous system — functions which involve the entering 
into activity of large tracts of nervous tissue extending over one 
or more of the organs just enumerated. I allude to the con- 
duction of sensations, the transmission of motor impulses, the 
so-called reflex action, and co-ordination of movement. 

In the first place, about the conduction of sensations. How 
are sensations formed in the spinal gray matter transmitted 
upward so as to be put within reach of the higher sensibility we 
call consciousness ? To this question only a very partial answer 
is possible, mainly with reference to the direction of conduction. 
It is quite surely ascertained that a sensation originating in an 
irritation of the right lower extremity is perceived by the left 
cerebral hemisphere, and the left half of the pons Varolii. In 
other words, the sensory nerves, or better, the sensory paths, 
all cross the median line somewhere in the spinal axis. We owe 
chiefly to the experimental inquiries and pathological observa- 
tions of Brown-Sequard the demonstration of two most important 
facts in this connection : (1) That these paths cross the median 
line (decussate) almost immediately after entering the cord, and 
then extend upward in the opposite half of the organ to the seat 



174 PHYSIOLOGY OF THE NERVOUS SYSTEM. 

of consciousness ; (2) and that it is the central gray matter, not 
the posterior columns, which contains these paths. This almost 
horizontal decussation has been shown to take place at the 
origin of every spinal nerve ; in other words, sensory decussation 
is complete throughout the spinal axis. There seem be good 
experimental and pathological reasons for believing that the 
perception of sensations (their appreciation by consciousness) 
takes place in the pons Varolii ; though cerebral action must 
intervene in the most complete perception, that including 
recognition of cause of irritation. I cannot leave the subject of 
transmission of sensations without adding a few words about a 
great law, a proper understanding of which is of great help to 
us in diagnosis — I mean the law of reference of sensations. By 
reference of sensations we mean the fact that when a sensory 
nerve is irritated at any point, at its termination (normal way), 
its middle, or at its origin in the spinal axis, the resulting sen- 
sation is felt in the parts to which the nerve is distributed. To 
illustrate : If I touch the table with my two outer fingers, I 
correctly refer the sensation to the vicinity of the pulp of these 
fingers ; if I strike the ulnar nerve behind the elbow, the greatest 
sensation is felt in the tips of the little and ring fingers, which 
this nerve supplies, and if I could irritate the sjDinal origin of 
the ulnar nerve, or parts in physiological relation with it higher 
up, the sensation would still be felt in the district supplied by 
the nerve. You are all aware that persons who have lost limbs 
by amputation feel the absent member a good while ; and they 
do so by virtue of this law. This law of reference of sensations 
holds good throughout the sensory tract (sesthesodic tract), from 
the special senses down. 

In the second place, -as regards the transmission of motor 
impulses from the nervous centres outward. Experiments and 
pathological observations have taught us that in the apparatus 
for motor manifestations (kinesodic tract) there is also a crossing 
over of paths. The motor fibres, or better, paths which transmit 
impulses to the right leg traverse the median line, though in a 
very different way from the sensory paths of the same limb. 
The right half of the spinal cord contains, throughout its length, 
the motor paths for the right limbs and right side of trunk ; no 
decussation takes place until the lower edge of the medulla 
oblongata is reached, when all the motor paths cross the median 
line and enter the left side of the medulla to extend upward to 



PHYSIOLOGY OF THE NERVOUS SYSTEM. 175 

the cerebrum. In the medulla and the pons Varolii the motor 
paths cross the median line rather higher up than the origin of 
the motor nerves. The importance of using the word paths 
instead of nerves, in the present state of our knowledge, is shown 
in this connection, since physiology and pathology teach that 
there is a crossing over, while anatomy seems to demonstrate 
that all motor nerves (anterior spinal roots) have their nucleus 
of origin in the corresponding half of the spinal cord ; the right 
sciatic nerve springing from the right anterior horn of the cord, 
the right hypoglossal and facial nerves from nuclei in the floor 
of the fourth ventricle on the right side of the median line. 

In the third place, the all-pervading function of reflex action — 
sensori-motor, excito-motor phenomena. The following defini- 
tion of a reflex action is perhaps sufficient in a theoretical sense : 
it consists in the transformation, by nerve cells, of a sensitive 
impression (with or without consciousness) into motion, chemical 
action, or ideas. The parts essential to the performance of a 
reflex action consist of a centripetal (sensory) nerve to transmit 
the excitation, a ganglion cell to transform it into nervous force, 
and a centrifugal nerve to carry the nervous impulse to the 
muscle, gland, or cerebral convolutions. The results of the 
activity of such an apparatus are motion (common muscular, or 
vascular), secretion, ideation. From this definition you can 
readily imagine that reflex actions occur in nearly every part of 
the body, in small segments of it as well as in large portions. 
A heart cut out of the animal's body will continue to beat some 
time in response to irritations. Contractions may be obtained 
by irritating a small portion of intestine removed from the body, 
and a small segment of the spinal cord will suffice to give reflex 
movements in the muscles supplied by that piece of cord. Reflex 
actions take place in all parts of the nervous system (spinal 
axis, cerebrum, sympathetic system), and at all times ; and it is 
through this kind of action that the most important bodily 
functions (including in part, certainly, cerebration) are produced. 
There is a tendency to make all active nervous phenomena of 
reflex nature, denying the existence of spontaneity in the animal 
frame ; and I must admit that a good deal* can be said in 
support of this extreme view. It would be quite out of place 
for me to enter into any details about individual reflex actions. 
I only ask you to remember that many mental manifestations 
are reflex in character ; that respiration, circulation, nutrition, 



176 PHYSIOLOGY OF THE NERVOUS SYSTEM. 

many acts of our life of relation (walking, etc.), are under the 
control of the law of reflex action ; and that many diseases are 
produced by just the same mechanism. 

Lastly, concerning co-ordination of movements. It has been 
thought, and that within twenty-five years, that there existed a 
"faculty " of co-ordination (what " faculties " have not been in- 
vented by fertile brains !) by the exercise of which our movements 
are regulated and made perfect. Such a view I need hardly 
tell you is quite opposed to present physiological and psycho- 
logical notions. Simple experiments performed long ago show 
the absurdity of this creation of the theorizer. If the cerebellum 
or cerebrum be removed from an animal, it is noticed that in the 
animal deprived of cerebrum there is no impairment of co-ordi- 
nation at any time : in the case of injury to the cerebellum inco- 
ordination occurs, and lasts for quite a while ; but as shown by 
Dalton, Lussana, and Weir Mitchell, this disorder ultimately 
ceases. I have already referred to the experiment of putting 
nitric acid upon a frog's anus after decapitation, with the effect 
of causing perfectly co-ordinate movements resulting in the 
removal of the acid ; which movements are so perfect as to have 
led one German physician at least to admit a consciousness and 
volition of the spinal cord. These experiments show that 
co-ordination is a function of many parts of the nervous centres. 
Another way of studying this function is by watching the phys- 
ical education of an infant. At first his motions are utterly 
purposeless and inco-ordinate, but by degrees he acquires the 
power of moving groups of muscles in a definite way, and at 
length comes to prehend, to stand, to walk, to speak ; and when 
older he may learn to eat, to play on the piano, to do astonishing 
feats of hand-skill. By analyzing this progress, we reach the 
conclusion that parts of the nervous centres are educated by 
repetitions of sensory impressions and of volitional motor 
impulses, leaving their impress upon groups of cells (so-called 
centres) which have the property I propose to call retentivity : 
the cells acquire the " habit " of acting in an automatic, necessary 
way. It is, furthermore, important to notice in this connection 
the fact that it is impossible for us to move one muscle alone by 
a volitional impulse ; in other words, the simplest act is co-ordi- 
nate. For example, the external rectus muscle of the right eye 
cannot be made to contract without consentaneous contraction 
of the internal rectus of the opposite eye ; in willed flexion of 



PHYSIOLOGY OF THE NERVOUS SYSTEM. 177 

the hand the extensor muscles contract as well as the flexors. 
The best theory of co-ordination, to my mind, is that which, 
denying all direct (continuous) connection between the cerebrum 
and individual muscles, admits the existence of educable or 
educated groups of motor cells in all parts of the spinal axis, 
which groups act as wholes upon the reception of a volitional 
impulse. We will to grasp a pen, and, after having learned, we 
do it without giving any attention to the details of the move- 
ments. The necessity of watching movements which should be 
performed in an automatic way is a serious symptom of disease. 

To resume, there are four generalized functions in the nervous 
system. 

1st. Sensation and perception are executed by means of paths 
which decussate almost horizontally in the spinal axis ; the con- 
duction being by the gray matter, not by the white columns of 
the cord ; coarse sensibility with doubtful consciousness has its 
seat in the pons Varolii ; perfect perception and appreciation is 
possible only with the help of the cerebral mass. 

2d. Motion is executed through motor impulses, which, 
starting from the opto-striate bodies (from cortex of cerebrum 
also ?) traverse paths which decussate almost opposite the motor 
nerves as far down as the lower margin of the medulla oblongata, 
where the paths for the trunk and limbs decussate in a bundle, 
to remain below this point in that half of the spinal cord whence 
arise the nerves going to the muscles. 

3d. Keflex action is the result of a transformation of an irrita- 
tion from the periphery into nervous force by a nerve cell, 
transmitted centrifugally by a second nerve. That all nervous 
phenomena are of reflex mechanism is not to be too positively 
denied. 

4th. Co-ordination is no faculty, but a function of every portion 
of the motor tract of the spinal axis from the origin of the third 
cerebral nerve down. 

There is not time for, nor had I the intention of, entering 
into an analysis of the restricted functions of the organs com- 
posing the nervous centres. Even Hitzig's and Ferrier's most 
interesting researches into the possible motor functions of the 
cerebral convolutions I must pass by, intending to speak of them 
in the course of remarks upon the cases which we shall study 
together this winter. 

There are a few* pathological laws logically allied to the 
12 



178 PHYSIOLOGY OF THE NERVOUS SYSTEM. 

physiological propositions enumerated above, which I want to 
submit to you. 

1st. Any disease of any part of the nervous centres may pro- 
duce two kinds of symptoms, which we should always attempt 
to distinguish : these being symptoms of irritation, consisting, 
according to the location of the lesion, in exaltation of ideas, 
delirium, in numbness, pain, and in spamodic movements ; and 
symptoms of destruction of parts, loss of mental power, anaesthe- 
sia, paralysis. Brown-Sequard was, I believe, the first to insist 
upon the exceeding importance of distinguishing these two 
classes of effects. 

2d. It should be borne in mind that irritating lesions may 
cause the second class of symptoms by producing an inhibitory 
(arresting) effect upon centres near or distant. 

3d. Ischaeinia of the nervous centres produces extreme irrita- 
tion symptoms, delirium, spasms, pain, and numbness, followed 
by loss of function of parts. 

4th. The effects of hyperemia are not satisfactorily known. 

5th. A want of equilibrium in the circulation of both hemi- 
spheres is a common cause of vertigo. 

6th. Almost any lesion of the nervous centres may disturb the 
nutrition of distant (non-nervous) tissues. 

7th. A generalized lesion of the convolutions of the brain 
produces, first, exaltation of mind and emotions, followed by 
abolition of the faculties, and a false general paralysis. 

8th. A lesion of one cerebral hemisphere gives rise to symp- 
toms (paralysis, numbness) in the opposite side of the body and 
face. The localization of the lesion in the left hemisphere about 
the fissure of Sylvius, is exceedingly likely to abolish language, 
spoken and written ; while lesions of the right hemisphere 
produce more severe palsy, set the emotions free, and endanger 
life more. 

9th. A lesion of the centre of the pons Varolii will produce 
general paralysis, with probably anaesthesia and changes in the 
bottom of the eyes. 

10th. A lesion in one-half of the pons Varolii will produce 
palsy with (probably) anaesthesia in the opposite side of the 
body. 

11th. Lesions of the cerebellum when in one lobe produce an 
incomplete hemiplegia on the opposite side, with marked eye 
and stomach symptoms. 



PHYSIOLOGY OF THE NERVOUS SYSTEM. 179 

12th. A suddenly produced lesion of the centre of the medulla 
oblongata will probably kill the patient at once by arresting the 
respiration. 

13th. A lesion localized in one-half of the medulla oblongata 
will give rise to hemiplegia and anaesthesia on the opposite side. 

14th. A lesion at the base of the brain, not on the median line, 
will produce a crossed palsy (as first indicated by Eomberg) ; 
palsy of body on side opposite lesion, and palsy of one or more 
cranial nerves on the same side as the disease. 

15th. Pressure anywhere within the skull may affect the nu- 
trition of. the optic nerves. 

16th. In lesions of the cerebral hemispheres accompanied by 
coma (apoplexy), the eyes are together turned and fixed toward 
the side of the lesion, and away from the palsied side. 

17th. A lesion occupying the whole thickness of the spinal 
cord, or its gray matter, will give rise to palsy of all parts below 
the lesion, i.e., below the distribution of nerves issuing from just 
above the lesion ; and such a paraplegia is necessarily attended 
by anaesthesia, and increased reflex movements in palsied parts. 

18th. A lesion in one-half of the spinal cord (hemisection, 
Brown-Sequard) at any point will produce paralysis with 
hyperesthesia on the same side as the lesion, and anaesthesia 
on the opposite side. 

19th. A lesion involving the posterior columns of the spinal 
cord produces neuralgia and ataxia of movements. 

20th. A lesion affecting the lateral columns of the spinal cord 
will cause a paralysis accompanied by contracture. 

21st. A lesion of the cells of the anterior horns of the cord 
alone will produce a palsy (no anaesthesia), accompanied by 
extreme wasting of muscles, and loss of electro-muscular reaction. 
Any part of the spinal axis may be the seat of this disease. 

22d. A lesion (destructive) of nerve trunks gives rise to a 
paralysis with anaesthesia, and rapid loss of electro-muscular 
reaction. 

23d. A lesion in the cerebrum and the opto-striate bodies may 
produce secondary lesions in the spinal cord and nerves. 

24th. A lesion of the spina] cord may cause secondary lesions 
upward and downward in the cord, and in nerves. 

25th. Lesions of nerve trunks may produce secondary lesions 
of the spinal cord. 



I.— ON HYSTEEICAL SYMPTOMS IN OEGANIC NEEY- 
OUS AFFECTIONS.* 

I purpose in this paper calling, attention to some points in 
the semeiology of diseases of the nervous system which have 
as yet been little studied — perhaps not at all in this country. 
While I do not know that any author has written upon this sub- 
ject, I wish to say that I was first led to observe the emotional 
state of paralytics through a remark of Prof. Charcot, of Paris, 
made either at the Societe de Biologie, or in his wards in the Sal- 
petriere Hospital, during the winter of 1869-70. I have since 
that time frequently spoken qf hysteroid symptoms as occurring 
in certain paralytics, in lectures, and have called the attention 
of the resident staff at the Epileptic and Paralytic Hospital on 
Blackwell's Island, New York, to the matter. I am also aware 
that Dr. Brown-Sequard has observed and studied such symp- 
toms in private practice. I should also say that a recent writer 
on the pathological physiology of the cerebrum, t has ably 
written of symptoms closely akin to those I shall describe, and 
has (after Brown-Sequard) pointed out how different are the 
symptoms produced by lesions of either cerebral hemisphere. 
I ought not to omit a reference to a remarkable paper, written 
a good while ago.,;]; in which pointed attention is paid to the 
emotional state of hemiplegic patients, whose intellectual con- 
dition is criticised by the author, Dr. B. W. McCready. 

The term "hysterical symptoms" is one which seems useful 
for purposes of clinical study and classification, and one, con- 
sequently, to be retained until we shall have exactly analyzed 
and re-classified the signs which, together, go to form the clas- 
sical hysterical state, or hysteria. 

* From the Archives of Eleetrology and Neurology for May, 1875. This paper 
was read before the N. Y. Society of Neurology and Eleetrology at the meeting 
for June, 1874. 

f De Fleury ; Du dynamisme compare des hemispheres eerebraux. Paris, 
1873. 

\ To what degree are the Intellectual Faculties affected in cases of Apoplexy 
and Hemiplegia ? N. Y. Journal of Medicine, new series, vol. iii., p. 203 (1857). 



HYSTERICAL SYMPTOMS IN ORGANIC DISEASE. 



181 



Before proceeding to relate the cases which form the basis of 
this essay, I may be pardoned for presenting in tabular form an 
analysis of the chief hysterical symptoms. 



Intellectual . 



Emotional . 



Sensorial 



Motorial . 



Simple eccentricity of conduct. 

Impairment of logical capacity. 

General ideational disorder (mania). 

Concentration of attention upon idea or sensation (ecstasy). 

Psychic pain. 

Laughter " w ^ co-incident spasms and secretions. 

Morbid impulses. 



Hyperassthesia . . -i 



Anaesthesia . 



Dysesthesia 



Hyperkinesis 



Akinesis 



" Special senses. 
Ovary (left). 

Infra-mammary region (left). 
Vertebral groove (left). 
Whole surface of body. 
' Special senses (hemiopia, amaurosis, 
deafness). 

{ Hemiplegic (left). 

Skin < Paraplegic. 

( Universal. 

Deep parts, i £°? °, f mus ™ lar sense. 
FF ( Retention of excretions. 

!Side of head (left) (clavus). 
Left breast. 
Various neuralgiae. 
Ovarian aura. 
Globus hystericus. 
Numbness. 
Sense of heat or cold. 
Hallucinations. 
Tetanoid seizures. 
Hystero-epilepsy. 
Local contractures. 
Postural spasms. 
Catalepsy. 

Cough and vomiting. 
Paraplegia. 

Hemiplegia (left) (not facial). 
Retention of excretions ; incontinence. 



f Excess of tears. 
" " urine. 
Secretory. . . . -\ " " intestinal gas. 
| Suppression of urine. 
[_ Local congestion and ischaemia. 

Imitation of various organic diseases (arthritis, etc.) 



Philosophically considered there is nothing specific in hys- 
terical symptoms ; they are functional disturbances of various 
organs, due to a morbid dynamical state of the nervous system. 
"With this understanding, it is not difficult to conceive of the 
very large number of symptoms which may receive, and justly 
in a certain sense, the qualification hysterical. The term hys- 



182 HYSTERICAL SYMPTOMS IN ORGANIC DISEASE. 

teria, and the adjective derived from it, I shall make use of 
without having much respect for it ; it was imposed upon no- 
sologists by the dominant theory of olden time respecting the 
pathological physiology of the morbid state in question; a 
theory holding that the uterus and its appendages were the 
seat of the morbid process. With the various theories of hys- 
teria, their rise and fall, and rehabilitation, I have only this to 
do : to state that most physicians to-day believe that the cen- 
tral nervous system is at fault, dynamically, in hysteria. Some 
writers teach that the spinal cord is most disordered in this 
condition ; others, that the organ whose badly performed func- 
tions are exhibited by " hysterical symptoms " is the cerebrum. 
The following cases are offered as illustrations of the proposi- 
tion that hysterical symptoms will present themselves in per- 
sons suffering from organic disease of the nervous system. A 
natural division of the cases is adopted, into cases of disease of 
the brain, and cases of disease of the spinal cord. Cases ob- 
served by myself are marked by a prefixed asterisk. 

CLASS A. 

Cases of Disease of the Spinal Cord. 

*I. — Female, E. E., 36 years, born in New York. Left hemiplegia, with 
paresis of right limbs — well marked hysterical symptoms; suppuration of left 
elbow joint; death, extensive central myelitis, with formation of cavities in 
cord. 

This patient was admitted to Epileptic and Paralytic Hospital, Sept. 17th, 
1868. Five years before had sudden right hemiplegia, cured in three months. 
About three years ago, while under strong depressing emotion, sat out of 
doors three days and two nights, when palsy of left lower limb was found. 
Two months before admission had pins-and-needles feeling in left arm, and 
gradually lost use of it. On reception, patient nervous; has left hemiplegia, 
(paresis of arm), with contractured leg in flexion ; palsied parts are seat of 
prickings, and are cooler than right limbs ; cannot retain urine ; speech (ar- 
ticulation) impaired. August 23d, 1871: has double rotatory nystagamus; 
no diplopia, pupils normal; no facial palsy; left hemiplegia with contracture 
of fingers (slight), of knee and foot. Complete anassthesia of left arm, slight 
(with numbness) of lower limb ; right arm only weak ; incontinence of urine. 

This patient exhibited almost constantly, during the several months I 
observed her, well-marked hysterical symptoms. She had a squeaky, tremu- 
lous voice, which changed easily into a natural tone when she was chided. 
Often she, began to cry, flush, and shed, tears on speaking to me, but if I 
passed on she would control herself. I may state that the larynx was normal. 
I often hesitated in my diagnosis because of the coincidence of these emotional 



HYSTERICAL SYMPTOMS IN ORGANIC DISEASE. 183 

symptoms with left hemiplegia. She died on February 16th, 1873, in conse- 
quence of exhaustion from the elbow-joint lesion, and a sacral bed-sore. The 
spinal lesion has been spoken of, and it remains only to add that no lesion 
was found in the cerebral hemispheres. 

*II. — Female, set. 32 ; single. Admitted to Presbyterian Hospital, Novem- 
ber 16th, 1872. Attacks of gastric pain and vomiting; fulgurating pains in 
extremities; palsy of left 3d nerve; locomotor ataxia. Sudden death; cere- 
bellar hemorrhage ; sclerosis of posterior columns of spinal cord. 

Many details of this case are interesting for the student of locomotor ataxia, 
but need not be reproduced here. Suffice it to say that this patient was re- 
markably emotional and hysterical in manner, so much so that hysteria was 
thought to be her only disease, manifesting itself in emotion, vomiting, numb- 
ness of left arm, and neuralgia. The nurses and the resident staff could not 
be fully persuaded that the patient had organic disease. Upon examining 
her on taking the service, January 4th, 1873, I became convinced, from the 
coexistence of fulgurating pains, ataxia in upper and lower extremities, and 
left 3d nerve palsy, that the case was one of sclerosis of the posterior columns, 
complicated by hysteria. Her death took place as follows, according to the 
hospital case-book: "April 6th, again hysterical; complains of left arm. 
April 14th, was taken with severe hysterical (?) convulsions at 3.30 p.m., 
which were quite continuous and lasted about an hour. There was no vomit- 
ing, and nothing to show pure hysteria, such as she had had before. When 
the convulsions ceased patient fell into a sleep, as was generally the case after 
the attacks of hysteria. In this sleep there was nothing remarkable, and 
about 7 p.m. the nurse, having her attention called to her by hearing a loud 
sigh, found her in apparent syncope. On the arrival of the resident physician 
the patient was dead. 1 ' 

*m. — Female, set. 23; single. Sclerosis of cord; hysterical symptoms. 
Seen October 20th, 1873. A nervous girl, with occasional irregularity of 
menstruation, but no dysmenorrhcea; at times hysterical laughter or tears; 
never convulsive attack. In July, 1871, while out walking, after having 
climbed a number of walls, felt weak and awkward in right leg; thought 
she had sprained her knee. There is not enough evidence to support this 
statement. Ever since she has had weak right- leg, without anaesthesia or 
numbness; at times more use of leg than at others; almost cured once or 
twice; of late has required help of crutch or friend's arm in walking. 
When I examined Miss DeP. I found paresis of the right leg, the loss of 
power being marked at ankle and toes ; there was doubtful weakness of the 
right hand ; I could not make out that the knee-joint was affected. The 
muscles of the right leg showed a slight diminution of reaction to Faradic 
current, and this agent also showed that sensibility to pain was a little dull 
in leg and foot. In view of the history of the case, the capricious develop- 
ment of the palsy, the absence of reliable signs of central disease, the 
presence of a strong neurotic element in the family, and the fact that strong 
emotions had been acting upon her, I concluded that the patient had a 
functional palsy of an hysterical nature. Strychnia was given her and 
Faradisra used. The specific effects of strychnia appeared, and the patient 
was decidedly tetanized for a while; this passed off, and when I last saw 



184 HYSTERICAL SYMPTOMS IN ORGANIC DISEASE. 

the patient, on December 11th, she was in about the same state as at the 
beginning of treatment. The unfavorable effects of the treatment led me 
then to believe that the patient had an obscure central lesion, probably 
sclerosis. 

In March or April, 1874, patient rapidly grew worse, becoming paraplegic 
and her hands showing paresis. In July she was placed in an irregular water- 
cure house, where extensive bed-sores formed, in consequence of want of care 
and of cold applications to the palsied parts. (She had continuous applica- 
tions for several days.) Exhaustion and pyaemia caused death, August 1st. 
The post-mortem examination showed disseminated sclerosis of the spinal 
cord. The brain not examined. I have the specimen in fluid, and will make 
a detailed report of the lesion. Dr. Chas. A. Leale, of this city, treated the 
patient during July, after the bed-sores had formed, and I made the autopsy 
at his request and that of deputy coroner Dr. Shine. 

IV. — Case by Duchenne. In a female who had true hysterical paraplegia, 
in Trousseau's service. Dr. Duchenne discovered that patient was suffering 
from the characteristic fulgurating pains of locomotor ataxia, and had noticed 
them five years. Dr. Duchenne diagnosed the coexistence of hysteria and loco- 
motor ataxia, and foretold that after the cure of the paraplegia the ataxic 
movements would reappear. This did happen after the use of Faradization. 

Electrisation localisee, p. G53, ed. 1872. 

V. — Female, set. — . Hysteria and sclerosis of the lateral columns of the 
spinal cord. The patient began to have attacks of convulsive hysteria 
about the age of 14 years, and occasionally thereafter; at 34, after such 
an attack, had a left hemiplegic contracture, which lasted a fortnight and 
suddenly disappeared. The next year there was a second attack of contrac- 
ture, at first hemiplegic, and then bilateral. After two years patient improved 
so much as to be able to walk about ; then a relapse occurred after an hyster- 
ical attack. Death by an intermittent disease. Post-moYteni examination by 
Bouchard showed sclerosis of both lateral columns of the spinal cord from 
medulla downward. The early history of case was taken by Briquet in 1850, 
and completed by Charcot at the Salpetriere. 

Charcot. Soc. med. des hopitaux, seance du 25 Janvier, 1865; in Gaz. heb- 
dom., 1865, p. 109. 

VI. — Female, set. 36. There were symptoms of sclerosis of various parts of 
the spinal cord and medulla oblongata; hysterical attack. At time of report 
patient still alive. She was the sister of two females affected with dissemi- 
nated sclerosis of nervous centres. From an early period she had had attacks 
of convulsive hysteria, throwing herself about in bed, uttering monotonous 
cries ; the respiration reduced ; apathy and seeming unconsciousness closing 
the scene. These attacks were usually brought on by emotional disturbances. 

Friedreich: Ueber degenerative Atrophie der spinalen Hinterstrange. 
Virchow's Archiv, 1863, Bd. xxvi., p. 391 et seq. Bd. xxvii., p. 1. (Case of 
Lisette Suss.) 

In the above six cases of organic disease of the spinal cord 
the following hysterical symptoms were observed and noted ; 



HYSTERICAL SYMPTOMS IN ORGANIC DISEASE. 185 

Abnormal emotional tendency in all cases. 

General nervousness in cases L, II., III. 

Tears and sobs upon slight provocation in case I. 

Tremulous variable phonation in case I. 

Disordered sensibility on the left side in cases I., II. 

Disordered sensibility in lower limbs in case IV. 

Vomiting in case II. 

Temporary paralysis in case IV. 

Contracture of limbs in case V. 

Convulsive attacks in cases II., V., VI. 

The commingling of these hysterical symptoms with the signs 
of organic disease has caused each case to present a peculiar 
problem to the examining physician. Sometimes the organic 
disease was wholly overlooked. In Trousseau's and Duchenne's 
case (IV.) the diagnosis of hysterical paraplegia had been cor- 
rectly made, and the sclerosis of the posterior columns of the 
cord not suspected by the former celebrated clinician. Charcot's 
case (V.) is still* referred to by him as one of hysteria, in which a 
lesion was found — a view which I would suggest is the inver- 
sion of the correct one. As regards my own cases, in Nos. I. and 
II., there were times when I was in much doubt as to whether 
all the phenomena were not functional. It was not until altera- 
tions of nutrition appeared in Eagles (I.) that I became firm in 
my conviction that there was a spinal lesion. Her general ap- 
pearance, manner, and speech, and the existence of many of her 
symptoms upon the left side, made up a more strongly marked 
picture of hysteria than I can give any idea of by words. In 
Miss L.'s case (II.) my faith in the significance of fulgurating 
pains and coexistent 3d nerve palsy kept me right. Even after 
I had made the diagnosis of sclerosis in this patient, the impres- 
sion of the medical gentlemen who saw her was that she was 
simply hysterical. In the case which I have added since reading 
this essay, Miss De P. (III.) I made a grave mistake in diagno- 
sis. I am glad to be able to publish this case as a guide for 
other physicians. 

From a study of these few cases, in the present state of our 
knowledge of pathological physiology, it seems impossible to 
point out any close genetic relations between the lesions found 
and the hysterical symptoms observed. In support of the view 

* Charcot : Lecpns sur les maladies du systeme nerveux, Paris, 1872-3, p. 316, 17. 



186 HYSTERICAL SYMPTOMS W ORGANIC DISEASE. 

that there was merely a coincidence in these six cases, I would 
adduce the following considerations : a. That the organic diseases 
were various. Two patients had sclerosis of the posterior col- 
umns of the cord ; two (including case III. not yet minutely 
studied) disseminated sclerosis ; one sclerosis of the lateral col- 
umns ; and one extensive central myelitis, b. That the number 
of cases of disease of the spinal cord in the books and periodi- 
cals I have been reading in several years is quite large, and 
that these six cases form an insignificant minority, c. A cer- 
tain number of cases of fatal hysteria have been examined after 
death, without any lesion of the central nervous system being 
discovered/'* 

After this conclusion of coincidence, I can only call the atten- 
tion of this society to one question connected with these cases, 
viz., that of their bearing upon diagnosis. There are reasons 
for believing that hysterical persons are sometimes treated for 
organic diseases of the spinal cord, which exist only in the phy- 
sician's mind ; and the cases I have related show how possible 
the converse error is when the hysterical symptoms are so 
prominent as to prejudice the physician ; and we may thus be 
led to attempt severe and unsuccessful treatment, and to make a 
false prognosis. 

The only way in which we can hope to avoid these errors is by 
having a clear understanding of what symptoms are hysterical, 
either essentially so or by association in groups ; and by being- 
prepared td appreciate and firmly believe in the true meaning 
of cardinal symptoms of organic disease of the spinal cord ; as 
the fulgurating pains and 3d nerve palsy of posterior spinal 
sclerosis, the paresis, ataxia, and peculiar speech of dissemi- 
nated nodular sclerosis, the alterations of nutrition, and the ab- 
normal muscular reactions to electricity in myelitis, etc. I 
believe that in minute and exact analysis of symptoms and 
symptom-groups lies our only safety. 

CLASS B. 

Cases of Disease of the Brain. 

*I. — Mrs. R. , 75. The subject of extensive arterial degeneration. On 
September 16th, 1873, a left hemiplegia was quickly developed without loss 

* L. Meyer : Ueber acute todliche Hysterie. Virchow's Archiv, 1856, p. 98, 
Bd. ix. 



HYSTERICAL SYMPTOMS IN ORGANIC DISEASE. 187 

of C. There was complete anaesthesia also on left side of body. In the course 
of three weeks there was no improvement in palsy, or anaesthesia, contracture 
appearing, and patient became very much depressed and careless of result ; 
this melancholy being in striking contrast with her previous condition. Xo 
improvement during winter. The general health remained remarkably good ; 
the heart and arteries showing signs of progressing disease. Xo fever. The 
most striking symptoms were of an hysterical nature ; the patient crying like 
a child for a moment, without any sufficient provocation. Upon the physician 
saying " Good morning, " this lady would burst into convulsive crying, with 
enormous facial contortions — no tears, but moaning just like a child. Suddenly 
the fit would pass off, the face become natural in an instant, and the patient 
exclaim, in a provoked way, "Oh, what an old fool I am!" During the 
short medical visit, in a few minutes, several such paroxysms would occur. 
Besides, in the last few months of life there were great physical restlessness, 
peevishness, loss of memory, hallucinations (eye and ear), and delusions. 
Death toward end of Ma}', 1874 ; no autopsy allowed. It should be added 
that this lady had possessed remarkable intellectual power, and unusual force 
of will; that during the winter, often immediately after crying attacks, she 
made very witty remarks. This lady was a patient of Dr. Win, H. Draper, with 
whom I saw her. 

*II. — Midwife, aet. 46. Left hemiplegia. Some prodromata in the shape 
of vertigo last summer, and much headache. Sudden palsy of left side with- 
out loss of C. "When examined at the Epileptic and Paralytic Hospital, 
Blackwell's Island, on January 30th, 1874: presents a complete left-sided 
palsy, with marked anaesthesia of left face ; great loss of sensibility in left 
arm and leg; does not know where arm lies ; has beginning secondary con- 
tracture. The intercostal muscles on the left side are much palsied ; the 
heart shows a faint apex systolic murmur; no gout or syphilis. In the 
middle of February marked hallucination of sight and hearing occur. Left 
(palsied) palm 1.4° C. warmer than right. In March, April, May, and 
since, patient is often very emotional, though perfectly rational. Bursts into 
tears with much facial contortion, saying she does not know why. Some 
improvement in leg; none in arm, though sensibility is everywhere much 
better. 

*III. — Male, aet. 28. Left hemiplegia, from probable embolism of a cere- 
bral arteiy. Came to Clinic for Diseases of the Xervous System at the 
College of Physicians and Surgeons, where it was learned that eight weeks 
before, when going to bed, he had a slight vertigo, with tingling in left 
side of tongue, and numbness, followed by loss of power in left limbs. Xo 
loss of C. Was in bed three weeks, because of inability to walk. Has 
since improved steadily. Examination shows a common left-sided hemiple- 
gia, with involvement of face and tongue. There is a basal systolic heart- 
murmur. On June 13th, 1874, very much improvement is noted. During 
examination the patient flushes. He states that since attack he has been 
unduly emotional ; when annoyed he has felt something rising from chest 
into throat, preventing speech ; has even wept a few times. 

*IY.— Female, 28 ; married. General paresis, hysterical symptoms. In 
June, 1873, began to complain of severe headache, universal, more severe on 



188 HYSTERICAL SYMPTOMS IN ORGANIC DISEASE. 

right side; not nocturnal, occurring in non-periodic paroxysms. Pain down 
the spine. In July gradual failure of sight; some loss of memory; using 
wrong words. Generalized weakness first noticed by friends during Decem- 
ber. No delirium. Since June occasional trembling of hands. From the 
first has had feeling of pins and needles in all her limbs at extremities. 
Has also had attacks of suffocation — something filling up her throat. Much 
constipation and nausea. In last two months less headache. Examination 
on November 11th, 1874 : patient so weak as to be hardly able to stand ; tot- 
ters much and inclines a little to left side; speaks loudly and complains of 
darkness of room. Speech clearly articulated and rational. Memory much 
impaired; hands very weak; no facial palsy or muscular atrophy. Oph- 
thalmoscope shows retinal vessels issuing from a uniformly red and velvety 
ground ; choked disks. No anaesthesia. Very deaf on left side. Has been 
very emotional at times, and now presents an hysterical manner. Has been 
seen several times by Brown-Sequard, who thinks that she has a brain tumor. 

*V. — Male, set. 18. Left hemi-chorea with paresis, 3d pair palsy on 
right side; probable lesion of right eras cerebri; hysterical laughter. This 
young man had paresis of left arm gradually developed from May, 1873. 
In July the choreic movements first a2^peared. On December 6th, left arm, 
leg and face are seat of rather ataxif orm choreic movements ; no palsy of 
eye muscles. Toward middle of January, 1874, hebetude, greater chorea, 
slight ptosis on right side. During late winter and spring progress in pare- 
sis and 3d pair palsy ; hebetude, but no loss of memory. Often laughs 
without cause, and finds great difficulty in stopping the laughter ; more cor- 
rectly, patient has, involuntarily, the special spasm of full laughter very 
often, without the psychical elements. August, 1874, complete 3d pair palsy, 
with left hemiplegia and chorea; at times some spasm in right arm; intel- 
ligence good. Patient died in September, but no autopsy could be obtained. 

VI. — Male, set. 43. Left hemiplegia. When twenty-two years of age had 
a chancre followed by secondary manifestations. Twelve years ago had an 
attack of hemiplegia, involving left side of face, and left limbs. The paral- 
ysis came on slowly ; soon after a midday dinner he noticed that the leg 
was weak. In the course of an hour this became entirely paralyzed, and the 
arm became enfeebled. At first, some improvement, none in last few years. 
Examination (spring of 1874) shows a left hemiplegia without contracture, 
except in face, where some muscles show some slight clonic spasms. Since 
a short time after the attack, has been easily excited, either to laughter or 
tears; on which account he has been unable to go to church. Mind clear; 
some impairment of memory. Has atrophy of right optic disk. 

Observation by Dr. T. A. McBride, of New York. 

VII. — Male, set. 39. Hysteria; left hemiplegia; semi-coma; thrombosis of 
basilar artery. Patient had been weak and stupid for two years. A fortnight 
before admission had vertigo and repeated attacks of a hysterical nature, 
with sobs, and bursts of laughter. Five days before death developed left 
hemiplegia, and passed into comatose state. 

John W. Ogle, in Trans, of Path. Soc. of London, 1864, p. 14. 

VIII. — Male, set. 59. Left hemiplegia; speech preserved; much anaesthe- 
sia of palsied limbs ; impairment of sight and hearing on left side. In three 



HYSTERICAL SYMPTOMS IN ORGANIC DISEASE. 189 

months some periodical delusions. Is at times given to laughing in an almost 
insane way ; after which there supervenes a strong tendency to weep. Death 
in eleven months. 

DeFleury: Du dynamisme compare des hemispheres cerebraux. Paris, 
1873. Pp. 12, 34. 

IX.— Female, aet. 74. Left hemiplegia; speech preserved; various altera- 
tions of sensibility (anaesthesia of left limbs, ear, and eye). When asked to 
perform movements patient cries and sheds tears. Later hallucinations and 
delusions. Death in nine months, with palsy of right side. 

De Fleury: Op. cit., pp. 124, 5, obs. xii. 

X. — Male, aet. 42. Right hemiplegia, with aphasia. Subsequently fre- 
quent epileptic convulsions, which diminished in frequency later. Intellect 
remained clear; partial recovery of limbs. " In the early years of his infirm- 
ities crying fits would often occur, especially when meeting an old friend, and 
no one near him to interpret, or when he would see the promotion of a class- 
mate, or on recovering from an epileptic attack, the tears would flow in tor- 
rents On the other hand, a jest, an anecdote, or frolic of 

any kind would excite such convulsive laughter that I have again and again 

feared for his life, from the evident determination to his head 

While engaged in any matter of interest his breathing becomes almost ster- 
torous; his salivation is profuse." 

Dr. B. W. McCready: To what degree are the intellectual faculties af- 
fected in cases of Apoplexy and Hemiplegia? N. Y. Journal of Medicine, iii., 
Sept., 1857, p. 203. 

XL — Male, aet. 60. Right hemiplegia and aphasia; intellect good. "The 
patient Wilcox weeps as often as the physician calls attention to his misfor- 
tune. His face becomes as much distorted as that of a weeping child, and 
his tears flow freely." 

Dr. McCready: Op. cit., p. 221, and p. 246. 

Xn. — Male, aet. — . Double hemiplegia. Left side palsied first. While 
paralyzed in left side only, and still able to speak (on first day), he was as 
sound in mind as ever in his life ; yet he wept frequently, with a child's dis- 
tortion of face. 

Case by Prof. A. Clark in McCready, op. cit., p. 236. 

XIII. — Male, aet. 58. General paresis — greater on left side. Symptoms of 
organic cerebral disease, general paresis, epilepsy, speech much affected, writing 
scarcely legible, intellect clear. "He does not weep, but laughs immoder- 
ately on every trifling occasion. He scarcely smiles, but is seized with con- 
vulsive, hysterical laughter." "He takes frequent and 

convulsive inspirations preparatory to uttering his words." No autopsy. 

Prof. A. Clark, in op. cit., p. 246. 

XIV. — Female, aet. 52. Partial left hemiplegia, right hemiplegia of two 
years' standing; palsied limbs rigid; absolute incapability of articulating 
sounds. "Every effort of the patient ends only in unintelligible stammering, 
interrupted by plentiful tears and sobs. Tears and sobs, such are the only 
means of expression in her power, and she uses them largely, for it is enough 
to feel her pulse or to speak to her to provoke an abundant flow of tears, a 
purple color of the face, and convulsive action of the muscles of respiration ; 



190 HYSTERICAL SYMPTOMS IN ORGANIC DISEASE. 

deglutition is embarrassed, and the patient makes us understand by gestures 
with her left hand, that the pharynx acts with difficulty." Intellect clear. 
Autopsy showed softening of the pons Varolii. 

Cruveilhier, in Anat. pathol., liv. xxi., p. 3. 

XV. — Female, set, 55. Four attacks of left and right hemiplegia, with 
great difficulty of articulation; understanding preserved. She weeps when- 
ever questioned. The autopsy showed a clot in the left hemisphere and cica- 
trices in the right hemisphere and in the cerebellum. 

Cruveilhier, op. cit., liv. xxxviii., p. 1. 

XVI. — Female, set. 60. Left hemiplegia. An apoplectic attack in a sub- 
ject of supra-orbital migraine. Although medical history is quite full, 
hysteria is not mentioned as having been present in earlier life. At beginning 
of attack had, with paresis of left limbs, ' ; une succession sans motifs de jrteurs 
et de ris." Death in twelve days after beginning of palsy, which, at the last, 
involved also right limbs. Autopsy showed softening of corpora striata, and 
of centre of pons Varolii. 

Cruveilhier, in Lalleuand: Recherches sur l'encephale, t. i., p. 101. 



Of the above sixteen subjects : 

Nine were males (III., V., VI., VII., VIII., X., XI., XII., XIII.). 

Seven were females (I., II., IV., IX., XIV., XV., XVI.). 

The paralysis was distributed as follows : 

Eight hemiplegia, two cases (X., XI.). 

Left hemiplegia, nine cases (I., II., III., V., VI., VII., VIII., 
IX., XVI). 

Double hemiplegia, five cases (IV., XII., XIII, XIV., XV.). 

Consequently fourteen out of sixteen patients had hemiplegia 
on the left side. 

The hysterical symptoms present were not very various. 

Undue emotions (tears and sobs) in fifteen cases. 

Irrepressible laughter in five cases (V., VI., VII., VIIL, X.). 

Anaesthesia of left side of body in four cases (I., II., VIIL, IX.). 

Globus hystericus in two cases (III., IV.). 

The lesions of the brain were determined by post-mortem 
examination only in a few instances. 

The following table represents the pathological diagnosis : 

Hemorrhage in both hemispheres, one case (XV.). 

Unknown " " two cases (XII, XIII.). 

Probable embolism of right cerebral artery, one case (III.). 
" thrombosis of " " one case (VI.). 

Unknown in left hemisphere, two cases (X., XL). 

right " four cases (I., IL, VIIL, IX.). 



HYSTERICAL SYMPTOMS IN ORGANIC DISEASE. 191 

Thrombosis of basilar artery, one (VII.). 
Softening of pons Varolii, one case (XIV.). 

" pons and corpora striata, one case (XVI.). 

Probable cerebral tumor, one case (IV.). 
Disease of right eras cerebri, one case (V.). 

Emotional symptoms were present in fourteen cases of left 
hemiplegia, and in two cases of right hemiplegia. This dispro- 
portion is enormous, considering that the records of many 
authors have been diligently searched for cases. I think that we 
may conclude that patients with right hemiplegia (who so often 
lose their speech), hardly ever lose control over their emotions ; 
while the subjects of left hemiplegia often do. Eight hemiple- 
gics are comparatively cheerful ; left hemiplegics are depressed 
and prone to weep. I am led by my recent experience to be- 
lieve that this law will be brought into much greater prominence 
by future statistics. 

The question of difficulty in diagnosis which occupied us while 
discussing the spinal cases, seems to me of minor importance in 
cerebral cases. Two of the sixteen cases are worthy of remark 
in this connection. In one instance (case XVI.) the paralytic 
attack was preceded by a well marked fit of hysterical weeping ; 
in another instance (case IV.) the exact diagnosis remained un- 
certain until the existence of organic brain disease (tumor ?) was 
made sure by finding well-defined choked optic disks. 

The thoughts which have arisen in my mind in connection with 
these relate to three points. 

a. The possible parallelism between cases of hemiplegia from 
organic brain disease accompanied by hysterical symptoms, and 
typical hysteria. 

b. The pathological physiology of some of the symptoms 
studied above, such as loss of control over the emotions, hemi- 
plegia, and hemi-ansesthesia. 

c. The new question of difference between the two cerebral 
hemispheres, in their functions and morbid susceptibility. 

a. I have already, at the beginning of this essay, laid the 
foundations for comparing hysteria and the effects of certain , 
cerebral diseases. 

1. In typical hysteria the emotional symptoms are the most 
common, and according to many authors the most character- 
istic. 



192 HYSTERICAL SY3IPT0MS IN ORGANIC DISEASE. 

In all the cases of cerebral disease above related there were 
undue emotional manifestations, or emotional movements not 
duly controlled. 

2. In typical hysteria many of the objective phenomena are 
almost always shown on the left side of the body ; and we may 
consequently feel sure that in these cases the right hemisphere 
is disordered. 

In nearly all of the above sixteen cases the right hemisphere 
was the seat of organic disease, and the symptoms were upon 
the left side of the body. 

b. The genesis of symptoms in cases of organic disease and of 
functional hysteric disturbance. Adopting as I do, with some res- 
ervations, Brown-Sequard's new hypothesis, that cerebral lesions 
produce the symptoms which point out their existence, not by 
destroying organs in the brain, but by setting up irritations which 
arrest (inhibit) the functions of other parts of the encephalon, 
I find no difficulty in understanding why the same symptoms 
may exist without as well as with a brain lesion. In typical 
hysteria the functions of parts of the encephalon included in the 
right hemisphere, or in physiological relation with it, are 
inhibited by a peripheral irritation, starting from a diseased or 
disordered sexual apparatus, or other part ; and, in case of 
organic cerebral disease, the same inhibitory action is produced. 
In both kinds of cases we may have loss of rational control over 
the emotions, loss of voluntary power over one half of the body, 
and loss of sensibility in the same part. 

In cases of hemi-ana3sthesia due to legions in the neighbor- 
hood of the thalami optici (Tiirck,* Charcot t), the explanation 
is, I think, the same — that a lesion in this particular locality is 
more likely to inhibit the functions of the (sub-cerebral ?) cen- 
tres for perception of sensitive impressions than lesions of any 
other part. I have long believed with Brown-Sequard, that it is 
just so in the case of aphasia : "We are forced by cases to deny 
the existence of an organ of speech in any convolution, yet are 
equally obliged by statistics to admit that a lesion of the pos- 
terior part of the left third frontal convolution, and immediately 
subjacent parts, is much more certain to inhibit the complex 
cerebral functions which co-operate to form articulate language, 
than any other cerebral lesion. 

* Sitzung der K. K. Akad. der Wissenschaften zu Wien, 1859. 
f Op. cit. , p. 271 et seq. 



HYSTERICAL SYMPTOMS IN ORGANIC DISEASE. 193 

c. I may be pardoned for adding a short review of what seems 
well established concerning the different results of lesions of 
either cerebral hemisphere. After the great advance caused by 
the numerous publications upon aphasia, Brown-Sequard pur- 
sued the inquiry. In 1870 :: ' he communicated his conclusions 
to the Biological Society of Paris. He found that after lesions 
of either hemisphere the following symptoms predominated. 

Left Hemisphere. Right Hemisphere. 

Eschars. 

(Edema. 

Palsy of sphincters. 
Aphasia. More fever. 

Palsy of organs of articulation. Greater mortality. 

Pulmonary congestions. 

More frequent deviations of 
eyeballs in coma. 

Greater palsy. 

The last three characters of left hemiplegia were added to the 
list in 1871.t He and Charcot also noticed, but did not publish, 
that when the right hemisphere was injured there was more 
emotional disturbance, and that of a depressed kind. 

Mr. Callender,^ in his remarkable papers on brain shocks, no- 
ticed the difference in the effect of lesions of either hemisphere, 
and expressed himself as follows in his second conclusion : 

" 2. The rapidly fatal results of bleeding into the right hemi- 
sphere outside the thalamus and corpus striatum, as compared 
with bleeding into the corresponding parts on the left side." 

Becently, De Fleury§ has pursued the same inquiry with 
similar and more striking results. He adds to the above table, 
that sensibility is more often and more deeply impaired when 
the right hemisphere is diseased. 

To sum up : Lesions of the right hemisphere give us 

More frequent and greater anaesthesia. 
Greater palsy. 

* C. R. do la Soe. do Biologic, 1870, pp. 27, 96, 116. 
f C. R, dc la Soc. do Biologie, 1871, p. 96. 

X Anatomy of Brain Shocks, in St. Bartholomew's Hospital Reports, iii., p. 415 ; 
v., p. 3. 

§ Du dynamismc compare des hemispheres cerebraux. Paris, 1873. 
13 






194 HYSTERICAL SYMPTOMS IN ORGANIC DISEASE. 

' Optic neuritis (Jackson). 
Eschars. 
Greater alterations of nutrition, -j (Edema. 

Pulmonary congestion. 
Fever. 

Palsy of sphincters. 

Hysterical symptoms (emotional). 

Lesions of the left hemisphere give us : 
Less palsy and anaesthesia. 
Aphasia. 
Palsy of organs of articulation. 

The general conclusions of this essay are : 

First : I have brought forward facts to show that many hys- 
terical symptoms may occur in diseases of the spinal cord and 
brain. - » 

Second : That in diseases of the spinal cord these symptoms 
appear merely as a matter of coincidence. 

Third : That in cases of cerebral disease the hysterical symp- 
toms have a deeper significance, being in relation to the hemi- 
sphere injured. 



Note. — Nov. 1st, 1874. — During the past summer and fall there 
have appeared in the Lancet a series of excellent clinical lectures 
by H. Charlton Bastian, on the common forms of paralysis from 
brain disease. In Lecture V., part 2 (Lancet of Sept. 26, 1874, 
pp. 440, 441), the author refers at length to the subject of differ- 
ence of symptoms when either cerebral hemisphere is injured. 



SYPHILITIC AND SIMPLE PACHYMENINGITIS.* 

I present to-night a section of the diseased dura mater pre- 
sented at the previous meeting by Dr. A. H. Smith, in order to 
prove not only that the diagnosis of gummy tumor was correct, 
but to exhibit some of the microscopic characters of the growth. 
I present also a second specimen, likewise a section of the 
dura mater, the lesions of which were simply inflammatory in 
character. It was removed from a gentleman of Texas who had 
been sent to me by Dr. Hadden, on account of persistent head- 
ache. Five weeks before that time the patient had been ex- 
posed to a very hot sun, and although not suffering from any of 
the symptoms of sun-stroke at the time, he subsequently was 
attacked with headache, from which he never entirely recovered. 
The headache was first seated in front, about the median line, 
over the region of the anterior fontanelle. It gradually extended 
backward in a symmetrical fashion, until it ultimately became 
seated in the occiput and back of the neck. His pulse was 55, 
and regular. He was examined very carefully, and nothing was 
found upon which organic disease of the brain could be based, 
and for the want of a better name the malady was called con- 
gestive headache. The patient went to the country, and, return- 
ing again in the fall, died. 

I did not see him at the time, but had been informed that he 
had died comatose. There had been no difficulty of deglutition 
at any time, nor paralysis of any kind. 

Dr. Clymer, who had seen the case in consultation, was re- 
ported as non-committal in regard to a diagnosis. 

The autopsy was made by Dr. Hadden, and showed a large 
clot over the convexities of both hemispheres on the external 
surface of the dura mater, and enveloped between it and another 
membrane of new formation. This latter was formed originally 
as the result of inflammation, was embryonic in character, and 

* A specimen presented to the New York Pathological Society, Feb. 9th, 1876. 
Reprinted from the N. Y. Medical Record, March 4, 1876. 



196 SYPHILITIC AND SIMPLE PACHYMENINGITIS. 

contained a large number of newly forming blood-channels. This 
condition of things was quite satisfactorily shown under the 
microscope to the members. The opinion was expressed that 
one of these blood-channels had ruptured, producing the effusion 
in the substance of the new growth, giving the said effusion the 
gross appearances of a clot between two membranes. 



A CLINICAL CONTRIBUTION TO THE STUDY OF POST- 
PARALYTIC CHOREA.* 

Having had the opportunity of observing two well-marked 
instances of this remarkable symptom-group, and as I am able 
to bring forward one of the patients, I make bold to call the 
attention of the Association to the subject. Before reciting the 
cases, it may not be amiss to say a few words on the growth of 
our knowledge of the subject. Although the symptom-group 
had been observed a number of years ago by various physicians, 
yet it was our distinguished Fellow, Dr. Weir Mitchell, who 
first called special attention to it, and gave it a name, in 1874 ; t 
but already in 1873,1 Professor Charcot, of Paris, had quite well 
described the movements, and indicated their association with 
hemi-anaesthesia. I would here beg to call attention to the fact 
that the description of the symptoms in my first case was written 
in December, 1873. Recently M. Charcot has written specially 
upon " post-he miplegic" chorea in its relations to hemi-anaes- 
thesia,§ and has expressed the opinion that both these symp- 
toms are caused by lesions situated at the outer and posterior 
borders of the optic thalamus, or in the posterior expansion of 
the corona radiata. Last year,|| Dr. W. R. Gowers read to the 
Royal Medical and Chirurgical Society an elaborate essay based 
upon a number of cases showing various degrees of post-par- 
alytic inco-ordination, including athetosis, athetoid movements, 
and post-hemiplegic chorea. 

A good description of a remarkable case of this condition, also 
coincident with hemi-ansesthesia, will be found in M. Schoepfer's 
Paris thesis.lF 

* Eeprinted from the Transactions of the American Neurological Association, 
vol.ii., 1877. 

f Post-Paralytic Chorea. American Journal of the Med. Sci., Oct., 1874, p. 342. 

% Lecons sur les maladies du systeme nerveux, t. i \ p. 279. 

§ Lecons, etc., 4 me fascicule, Paris, 1877, p. 329. 

|| On Athetosis and Post-hemiplegic Disorders of Movements. The Lancet, 1876, 
vol i., p. 709. 

TT Considerations sur un cas d'hemianesthesic avec mouvements ataxiques, suc- 
cedant a une hemiplegie du raerae cote. These de Paris, 1876. 



198 STUDY OF POST-PARALYTIC CHOREA. 

I now pass on to relate the cases which have come under my 
observation. 



Case I. — H. H. H., aged eighteen years ; by occupation a clerk, and a 
native of this country, was referred to me by Dr. Fisher, December 6, 1873. 

He was a fairly developed boy, with apparent good general health. He had 
been well until last April, when he began to suffer from diffused headache, 
more temporal, but not one-sided. One day in May he went down to his 
office feeling as well as usual, and began his work with full use of all his 
limbs. About 11 o'clock a.m. was writing, leaning on the desk, the left arm 
thrown forward and its fingers steadying the paper. He got up to cross the 
room with a book in his left hand, but the book fell to the floor, and he then 
first became aware that his left arm was weak. There were at the time no 
subjective or sensory symptoms, cerebral or peripheral. The leg was not in 
any way affected. He was able, though awkwardly, to feed himself at dinner 
that evening. 

The paresis gradually increased until the middle of July, and since that 
time there has not been much change. 

Shortly after the attack, within a few days, patient noticed numbness of 
the left hand and forearm, and this has somewhat increased. 

In the early part of July convulsive movements began in the left hand, and 
have since become greater in force, and have extended to other parts of the 
left side. The left leg began to twitch and grow weak also in the first part 
of July, and since October slight twitching has appeared in the lower part of 
the left side of the face. Lately sight has become impaired, but hearing is 
preserved. 

There have never been any symptoms on the right side.. He has never had 
any epileptic or epileptiform seizures. Memory has somewhat failed. 

In the middle of July there appeared double vision, which gradually passed 
away. At the same time he had severe bi-temporal headache with nausea, 
lasting one week. The latter symptom never recurred, and it was probably 
caused by diplopia. No rectal or vesical symptoms. No dysphagia. 

Examination reveals left hemiplegia with peculiar spasmodic movements 
of the palsied parts. The left arm and leg execute all movements, though 
feebly and awkwardly. The dynamometer shows a strength of 30° in the 
right hand and 10° in the left; can barely stand on left foot alone; no evi- 
dent facial paralysis; tongue points a little to the left. There is now no 
twitching in the face. The left pupil is a trifle larger than the right; both 
are active. The ophthalmoscope shows both optic disks congested, their out- 
lines blurred, and traces of exudation along the blood-vessels. There is no 
evident palsy of any muscle about the eyes, though the eyes converge abnor- 
mally. Fields of vision not impaired. 

There are strong choreiform (this is the word used in notes made at the time 
of first seeing patient — 1873) movements in the left arm, shoulder, and leg. 
These parts are constantly agitated during waking hours, but quiet during 
sleep. The arm is more or less rigid, and its various parts perforin large oscil- 
lations. The movement is increased by emotion or by the attempt to perform 



STUDY OF POST-PARALYTIC CHOREA. 199 

voluntary acts; lie cannot carry a glass to his lips. Eyes being closed, lie 
can, after groping a little, place fore-finger on tip of nose. There is, how- 
ever, a marked ataxiform element in the spasm. The muscles of the shoulder 
and the trapezius are involved, but not the muscles of the trunk and neck. 

Sensibility (to contact and pain) is slightly impaired in fingers and hands ; 
the points of the aesthesiometer must be separated from 3 to 5 mm. to be dis- 
tinguished on the finger-tips. 

January 20th, 1874. — Chorea is as before. There is much hebetude. On 
the right side there is marked ptosis with weakness of the internal rectus 
(palsy of third nerve). 

We now have a form of crossed paralysis, i.e., third nerve on the right 
side, body on the left. The right cms cerebri is probably involved in lesion. 

January 28th. — Greater evidence of palsy of third nerve on right side; 
more chorea in left limbs; left side of face paralyzed; speech thick, saliva 
escaping from the mouth. There is marked anaesthesia in range of left supra- 
orbital nerve. Sister states that he has frequent partial syncopal attacks 
without spasm or loss of consciousness. Is this petit-mal? 

March 1st. — Much as before, but weaker. While speakiDg has spasm in 
left side of face which simulates involuntary laughter. 

This patient died during March without presenting any new 
symptoms, and I was unable to make an autopsy. 

Judging by the symptoms, the lesion must have been placed 
just above the motor tract of the right crus cerebri, acting upon 
it by pressure. 

It is probable that the lesion was hemorrhage with subsequent 
inflammation about the clot, though it may have been a tumor. 
I am in doubt on this point, because I am not disposed to at- 
tach much value to the ophthalmoscopic examination which I 
made. The certain diagnosis of neuro-retinitis would, of course, 
have strengthened the probability of there being a tumor in the 
locality indicated. 

Case II. — J. P., aged 26, a clerk, was referred to me by Prof. Edward Cur- 
tis, on May 24th, 1877. 

I learned that this young man had been well up to April 16, 1876, when he 
had, in the street, an attack of right hemiplegia. He did not fall down ; was 
able to walk with help to a street car, yet knew nothing of what afterward 
occurred until the next day. This was either late loss of consciousness, or 
amnesia. 

On the next day speech was much affected, he could not recall names and 
addresses of persons ; his right arm was powerless, and there was much numb- 
ness of the right cheek and arm. " Could only see with inner half of right 
eye." Right leg weak. In a day or two speech improved. 

In three weeks he walked well, but the arm did not regain its strength for 
three months. » 



200 STUDY OF POST-PARALYTIC CHOREA. 

During this period of improvement irregular movements appeared in the 
right arm, and have persisted. No jerking in face, leg, or on the left side of 
the body. Imperfect vision persisted. The numbness continued marked in 
toes, finger-tips, cheek, and tongue, on the right side. The numbness on 
the right side of face and tongue never quite reached the median line. 

In August (four months after attack of paralysis) had an epileptiform 
spasm, followed by loss of consciousness lasting until the ensuing morning. 

In April, 1877, had a second epileptiform attack. At times feels queerly 
in his head, " as if a spasm was coming on." Has not suffered from head- 
ache or dizziness. 

Inquiries into patient's past history show that six or seven years ago he had 
several chancres, which did not heal for three months. Had no buboes. 
Never had any eruptions, strictly speaking; but his legs "ulcerated," and he 
has since frequently suffered from ulcerated sore throat. At no time any 
osteocopic pains. Sight was good until after attack of paralysis. Memory is 
a little impaired. 

Examination. — Patient's speech is imperfect, a sort of aphasic stammer- 
ing. It would appear that he has always had a somewhat similar defect. 
The right leg has almost perfectly recovered, but the right hand is not quite 
as strong as the left, and jjresents curious abnormalities of movements. The 
dynamometer test shows for the right hand 18 c -22° ; for the left 28° and 28°. 

The peculiar movements are of two sorts : 

1. While the patient is seated quietly, with his hand resting on his thigh, 
it (the hand) may be seen to be agitated by slight rhythmical movements of the 
type observed in paralysis agitans. These are not truly constant, but seem to 
be provoked by observation or by the patient's own watching of the hand. 

2. During attempted use of the extremity, an ataxiform movement is de- 
veloped ; or, more properly speaking, a movement compounded of the want 
of combined and harmonious action of large muscular groups which is char- 
acteristic of the ataxic movement, and of the totally irregular and capricious 
muscular contractions which constitute the choreic type. On the whole the 
movement is more like that of ataxia ; i.e., more or less regularly oscillatory. 

The right leg is not the seat of any tremor, ataxia, or chorea ; and the left 
side of the body shows none.. 

There is no marked facial palsy, but the right naso-labial crease is less dis- 
tinct than the left. The tongue deviates a little to the right. These points 
make it probable that the paralytic attack in April, 1876, was one of common 
typical hemiplegia. 

There exists a degree of right hemi-anaesthesia. To slightest contact, ac- 
cording to patient's jDositive statement, the anaesthetic district of the face 
begins at a point 1 cent, to the right of the median line. The sesthesiometer 
and the simple contact test show slight loss of sensibility on the right side of 
the face. On the finger-tips the points of the sesthesiometer cannot be distin- 
guished at a less distance apart than from 5 to 8 mm. on the right side, while 
on the left they are distinguished at 3 mm. Pricking is well felt. 

The fault in vision is in the shape of incomplete hemiopia ; the right tem- 
poral and the left nasal halves of the fields being obscured, as shown in 
the cut. 



STUDY OF POST-PARALYTIC CHOREA. 



201 





RIGHT EYE. 



LEFT ETC. 



The pupils are equal and normal ; the ocular muscles act well ; and the 
ophthalmoscope shows no lesion which I can appreciate. 

A careful examination of the throat does not reveal any cicatrices. The 
heart is normal. 

My diagnosis was slight cerebral hemorrhage just outside the 
left thalamus opticus. Yet I was unwilling not to give the pa- 
tient the benefit of the doubt that syphilis had led to arterial 
disease and rupture, though the history was not one that pointed 
to the existence of syphilis at any time. Yet how often are 
serious syphilitic nervous lesions developed after equally or 
more incomplete chains of evidence ? Consequently I have given 
this patient mercury internally, and have brought about a degree 
of salivation.* 

Eemarks. — These cases are strongly in support of M. Charcot's 
proposition. In the first place, we observe in both the co-exist- 
ence of hemiplegia, hemi-anaesthesia, and choreiform movements. 
In case I., a positive symptom, palsy of oculo-motorius nerve, 
points to a lesion near the crus cerebri — probably just above it. 
In the second, there is a strong probability that the lesion is not 
far from the same part — near the thalamus opticus. 

In my second case, the occurrence of hemiopia is of great inter- 
est, because it will be remembered that Prof. Charcot has re- 
cently t denied that a lesion of the hemisphere could produce 
hemiopia. In the absence of a post-mortem examination, I 
would not be understood as claiming that the case positively 
contradicts M. Charcot's statement ; yet it must be admitted, I 
think, that there is no probability that there was in this case a 
second lesion affecting one of the optic tracts. 

* July 1, 1877.— I may now add that salivation, followed by the administration 
of iodide of potassium in doses of 12. a day, made no change whatever in this pa- 
tient's symptoms. I have now advised him to cease treatment, and hope for spon- 
taneous improvement. 

\ Lecons sur les localisations dans les maladies du cerveau. Paris, 1876, p. 126. 



CONTKIBUTION TO THE STUDY OF LOCALIZED 
CEEEBKAL LESIONS * 

It has fallen to my lot to observe during life and to examine 
after death a number of cases in which localized cerebral lesions 
gave rise to definite peripheral symptoms, and it has appeared 
to me that these cases might profitably be studied in the light 
of recent experimental and pathological researches upon the 
functions of the brain. In other words, I shall endeavor to de- 
termine the bearing of these cases upon the recent hypothesis 
of the localization of functions in the cortex of the brain. 

I shall divide my cases into three categories : 1st. Cases in 
which localized lesions gave rise to Aphasia. 2d. Cases in 
which localized lesions gave rise to Paralysis. 3d. Cases in 
which localized lesions gave rise to Spasm. 

PART I. 

CASES IN WHICH A MOKE OE LESS LIMITED CEREBRAL LESION 
PRODUCED APHASIA. 

Case I. — Cerebral softening from arterial degeneration ; aphasia 
and right hemiplegia. 

A woman, aged seventy-five years, was admitted to the Epileptic and Par- 
alytic Hospital on Blackwell's Island, January 17th, 1873. The history of 
the case is very meagre, and only states that when attacked she screamed, 
threw up her hands, and became insensible. On recovering from insensi- 
bility it was found that she had completely lost speech, and was paralyzed in 
the right side, face, and limbs. No mention is made of the state of sensibil- 
ity; but, as I am in the habit of always looking for hemi-ansesthesia, I feel 
sure that the case was one of common hemiplegia. I also feel very positive 
that during the six months of the patient's stay in my ward she greatly 
regained voluntary power on the right side, being able to take a few steps 
alone, and to move her arm quite freely. Aphasia, however, remained com- 
plete. 

The patient died on July 12th, 1873, and careful notes were made at the 

* Reprinted from the Transactions of the American Neurological Association, 
vol. ii., 1877. 



LOCALIZED CEREBRAL LESIONS. 



203 



time of the post-mortem examination on the 13th. I reproduce only those 
relating to the state of the brain, making, however, the preliminary state- 
ment that the valves of the heart were free from disease. 

Dura mater not abnormally adherent to the skull, and healthy at base. 
Moderate sub-arachnoid effusion at the top of the brain, and a great deal at 
its base. 

Both anterior lobes have undergone more or less atrophy. The convolu- 
tions of the left parietal lobe, beginning at a point an inch and a half from 
the median line, bulge and form a soft and yellowish tumor. The pale yel- 
lowish color of the affected convolutions is in marked contrast with the 
injected appearance of the rest of the brain. Over these diseased convolu- 
tions there is more sub-arachnoid effusion than elsewhere. After removal 




PIG. 2. 



FIG. I.— PROFILE OF LEFT HEMISPHERE. FIGS. 2 AND 3 TRANSVERSE HORIZONTAL SECTIONS OF 
SAME SHOWING EXTENSIVE RAMOLLISSEMENT. 

of the brain, and escape of the greater part of the serum, the left parietal 
lobe appears sunken, and there results an appearance like a loss of substance 
as large as a small walnut. The basilar and other large arteries of the circle 
of Willis are open, and nearly free from changes. 
Careful inspection shows no externally visible lesion in the left frontal lobe, 



204 LOCALIZED CEREBRAL LESIONS. 

its third convolution, and the island of Reii. The depression in the parietal 
lobe measures six and a half cent, square, involving all of the lobe except 
the part lying next to the great longitudinal fissure. 

Two small old lesions are found in the right hemisphere, one lying at the 
external margin of the extra-ventricular nucleus of the corpus striatum, just 
behind the island of Rcil ; the other in the posterior part of the same (lentic- 
ular) nucleus. Both arc small cavities, the size of large beans. 

The following is a transcript of notes which I made upon the state of the 
left hemisphere. I was very careful in studying the limits of the ramollisse- 
ment because at first sight the case seemed to be one opposed to Broca's 
hypothesis of aphasia. The extent of the lesion was studied, after hardening 
for a few days in a solution of bichromate of potassa, by means of transverse 
horizontal sections, and tracings made on transfer paper upon each section 
by Mr. George Wright. Each tracing was afterwards carefully reduced and 
drawn to a scale, with a sketch of the appearance of the unsliced hemisphere. 
This last drawing, Fig. 1, shows that the greatest destruction of tissue has 
taken j)lace in the parietal lobe proper. Posteriorly and inferiorly a degree 
of degeneration of the convolutions may be traced almost to the confines of 
the occipital and sphenoidal lobes ; while anteriorly, after having destroyed 
in great part the ascending frontal convolution, it extends over a portion of 
the second frontal gyrus. 

Sections were made through the hemisphere in the planes indicated by 
lines in Fig. 1, and the morbid appearances seen on each section, were 
accurately traced on paper. Fig. 2 shows that the atrophy has destroyed a 
large part of the upper posterior part of the hemisphere. Fig. 3 demonstrates 
that the hinder part of the third frontal convolution is likewise involved. 

By this method of examination the case is restored to the category of 
common cases of aphasia, viz., those supporting Broca's hypothesis. 

Bemakks.— I consider this case as doubly instructive. 

First, in a positive manner, as showing that a superficial degen- 
eration of the cortex of the brain (involving Broca's centre for 
speech) may produce aphasia of the most complete kind. 

Second, negatively; because, in spite of the destruction of gray 
matter in the regions which Terrier makes out to include nearly 
all the motor centres for the face, arm, and leg, a great degree of 
voluntary power was regained by the patient in a few months. 
Hence it would appear that other parts of the injured hemi- 
sphere had acquired controlling power over the limbs of the 
opposite side. 

Case II. — Embolism of the left middle cerebral artery ; softening of 
the brain ; aphasia, and right hemiplegia. 

Mrs. Gr., seen in consultation, with Dr. William Pierson, jr., of Orange, 
K J., on May 8th, 18T7. With the exception of a badly acting heart and a 
tendency to gout, Mrs. G. enjoyed fair health and had three children up to 



LOCALIZED CEREBRAL LESIONS. 205 

1ST"). Late in November of that year she had a moderately severe miscarriage. 
On December 7th, at 7.30 p.m., experienced a sudden attack of common hemi- 
plegia on the left side, without loss of consciousness. Speech was much 
impaired by defect in articulation. The palsy passed away rapidly, though 
she dragged her left foot for some days. Power of articulation slowly 
regained. Patient's husband is an unusually well-informed gentleman, and 
states that trouble in speech was surely not aphasiform. There remained a 
want of proper action of muscles of throat and larynx ; patient not knowing 
how to pitch her voice afterward. 

On January 13th, 1876, a second attack of left hemiplegia occurred. 
Consciousness was lost for a moment. Left leg but not left arm palsied. All 
symptoms, except a degree of excitement, passed off the next day, after a 
long sleep. 

On April 1st, at 1 a. if., had a first epileptic fit while asleep; had full spasm, 
slight frothing at mouth, loss of consciousness, stertorous breathing, and a 
heavy terminal slumber. On April 29th, second fit ; falling like a shot to the 
floor. Has had a few attacks since ; only two, however, since last August. 
One was two weeks ago. 

Present paralytic attack occurred twelve days ago. On April 26th, came 
down stairs, and in a few minutes was found fumbling a door-knob. With- 
out apoplectic symptoms, complete right hemiplegia and aphasia were de- 
veloped. Possibly a little return of voluntary movement has taken place in 
the right limbs. Xo return of speech. Indeed, the aphasia has been so 
absolute, that even sign language has been lost, and patient's friends have 
thought her deprived of her faculties, though she has been conscious at all 
times. There has been no retention of urine, no tendency to bed-sore. Food 
has hardly been taken, and patient's respirations have been extraordinarily 
frequent. 

Examination shows complete right hemiplegia, with marked loss of sensi- 
bility in the paralyzed limbs. The face is hardly distorted. Absence of 
spoken and gesture language as above, but patient looks intelligent. Pupils 
very wide, but equal. Breathing very rapid, .50 or 60 in the minute. Pulse 
slightly irregular, beating about 90 in the minute. The heart is enlarged, 
apex in sixth intercostal; cardiac sound can be heard away from the patient, 
as far as two feet. Xo distiuct murmur can be heard, but the heart sounds 
are completely reduplicated. Oral temperature 37.. j° C. No sensibility to 
pinching on the right side, and only slight on left ; but this may be owing to 
rapid respiration. There is a marked tendency to turn eyeballs to the left, 
away from the paralyzed side. Lungs are free from deposit or congestion; 
the optic disks are' normal. 

I learn that Mrs. G. has had pains in the small joints, with atrophy of mus- 
cles of the hand, and. in the last few years, gouty knees. From childhood she 
has had a curious affection of the heart, characterized by dyspnoea, hard beat- 
ing of the organ, and by transmission of its sound to a distance from the 
body of two to four feet. My diagnosis was embolism of various arteries in 
both hemispheres: the last attack being due to blocking of a branch, or 
branches, of the left Sylvian artery, and consequent softening of (probably) 
the third frontal and the ascending frontal convolutions. 



206 



LOCALIZED CEREBRAL LESIONS. 



In spite of an attempt at supporting treatment, Mrs. G. died on May 11th. 

For notes of the post-mortem examination, made on the same day, six hours 
after death, I am indebted to Dr. Pierson. 

"The membranes and sinuses of the brain were normal. The surface of 
the third frontal convolution of the right side was yellow in color, with a 
tough, elastic feel. This lesion, extending through the gray matter, was 
about 3. cent, square and .5 centimeter in thickness. The same change was 
also found, but to a less extent, in the same part on the left side. The left 
middle cerebral artery was plugged by an embolus at a point 1.25 centm. 




CASE II.— SOFTENING IN BOTH HEMISPHERES, IN CONSEQUENCE OF EMBOLISM. 

from its origin. A spot of cerebral tissue, about the size of a quarter of a dollar 
(3 centm. in diameter), supplied by this artery, was in a softened state; it was 
yellow, tinged with red, broken down, and of semi-fluid consistence. The 
situation of this lesion was external and posterior to the anterior cornu of the 
left lateral ventricle, and corresponded to that part of the third frontal con- 
volution which is known as the island of Reil. The softening was confined 
to the white substance, and did not implicate the surface. The rest of 
the encephalon was normal. 

"The heart was much diseased. The mitral valves were much thickened, 



LOCALIZED CEREBRAL LESIONS. 207 

and nodules of atheroma could be felt at various points. The two leaves of 
the valve were joined together, constricting the auriculo-ventricular opening 
to such an extent that it would not admit the end of the finger ; there was 
stenosis and insufficiency." 

Unfortunately the brain was not preserved for more minute examination, 
so that the existence of microscopic changes in the rest of the territory sup- 
plied by the left Sylvian artery remains a matter for speculation. 

The notes and the plugged artery were brought to me by a student of Dr. 
Pierson, and I asked him to mark out for me on plates in Ecker's and Luy's 
books the location of lesions. The accompanying diagrams are constructed 
faithfully after this gentleman's indications, and Dr. Pierson's corrections. 

Remarks. — The complete aphasia in this case was undoubtedly 
due to lesion of the third convolution and of the anterior folds 
of the island of Reil. We have in this case an addition to the 
large list of cases supporting Broca's hypothesis. It is remark- 
able that such complete hemiplegia should have existed without 
apparent lesion of those parts which are more directly connected 
with the movements of the arm and leg, viz., the ascending fron- 
tal and parietal convolutions. These convolutions are supplied 
by the artery which was plugged, and it is very probable that 
microscopic study would have shown them to be full of granular 
bodies. They may have been saved from gross softening by an 
unusually free anastomosis between the final branches of the 
plugged Sylvian artery and other arteries in the same hemi- 
sphere. It is also possible that a part of the hemiplegia was due 
to pressure upon and anaemia of parts adjacent to the softened 
spot; and that, had the patient survived, the paralysis would 
have disappeared in a few weeks. 

Another interesting feature of the case lies in the connection 
between the very localized lesion in the right hemisphere and 
the first attack of hemiplegia. This attack, it will be remem- 
bered, was characterized by slight and transitory paralysis of 
the limbs, and by very great defect in articulation. Indeed, it 
is said that the patient never recovered the full use of her vocal 
organs. From this we might be led to infer that the function 
of the third frontal convolution on the right side in right- 
handed human beings is intimately connected with the muscles 
governing the movements of articulation and phonation. 

Case III. — Chronic meningitis almost limited to the posterior part 
of the third left frontal convolution: extensive central cerebral soften- 



208 LOCALIZED CEREBRAL LESIONS. 

ing / epilepsy, chronic aphasia of varying degree, rigid hemiplegia ; 
death in status epilepticus. 

A male, age forty-seven years, was admitted to the Connecticut General 
Hospital for the Insane, at Middletown, on November 29th, 1873. 

For a full account of the case and for the post-mortem examination I am 
indebted to my friends Drs. A. M. Shew and W. B. Hallock, medical officers 
of the hospital. 

The patient was sent to the hospital because of "dementia." It was 
learned from his wife that he had had three ' ' apoplectic " attacks. The first 
occurred in April, 1873, and consisted in loss of consciousness and general 
lspasm. After this he had at short intervals some few slight "spasms." In 
July had a second severe attack of same kind as the first, followed by slight 
hemiplegia. Three weeks later had a third seizure, after which he was in a 
state of delirious mania, which still continues. 

On admission, mind is in dementia, the pupils are very small, articulation 
good, the tongue protrudes straight, and the only palsy apparent is in right 
lower limb. At times is violent and has insomnia. Speech very incoherent. 
In December it is noted that palsy is less, but that legs are not well co-ordi- 
nated, and that hands tremble. 

In middle of January, 1874, patient is calmer, and more rational, but 
speech is imperfect. "He talks plainer, seems to have ideas, but has for- 
gotten words." Aphasia. 

Feb. 17t7i. — At two o'clock p.m. had an epileptic attack, with paralysis of 
right side ; tongue deviating to the right. Four other spasms in three- 
quarters of an hour ; each characterized by usual symptoms, foaming at 
mouth, stertor, upturned eyeballs. 

March 0th. — Is up and about the ward. Is more coherent than for some 
time. Hallucinations of sight in the night. 

March 30th. — Is discharged improved. For some time past the difficulty 
in speech has taken the form of amnesia, and his writing has shown the same 
characteristics. 

Re-admitted June 29th, 1874. Aphasia still present, and he seems to ap- 
preciate the trouble. "I like that fountain I drink from three times a week," 
meaning I like that medicine I take three times a day. He knows that he 
calls things by wrong names and is thereby irritated. "I wish you would 
sell me," meaning bleed me. "Oh, I can't talk." 

July 26th. — Yesterday and last night had ten attacks of an apoplectiform 
character, without paralysis. These must have been epileptic seizures. 

Sept. 2*dtli. — Rose as usual, made up his bed nicely. At table was unable 
to grasp knife and fork. In twenty minutes complained of bad smell and 
dim vision, then had a general convulsion. Had ten attacks in the course of 
an hour. There was foam at the mouth, and more twitching on the right 
side of the body. In a few days was up again. 

Oct. 20th. — Three epileptic attacks in a few minutes. This is the third 
time that patient has had prodromata, consisting of nervousness, a slight de- 
gree of paralysis of right side; has gone to his room and made signs that he 
was ill. 



LOCALIZED CEREBRAL LESIOXS. 209 

Oct. 2\st. — Xo paralysis after attacks; some excitement in night. 

Xor. ldtli. — Is in good physical health; has hallucinations of sight; aphasia 
continues marked. 

Jan. 8th, 1875. — After dinner (1 r.M.) had an epileptic seizure, and at 5 
p.m. the attacks followed each other rapidly. The right side is completely 
paralyzed. 

Jan. dth. — Has been in status cpilepticus all night, and must have had 
nearly four hundred convulsions. Died at 3.15 a.m. 

Autopsy Jan. 10th, thirty-two hours post mortem. Calvarium normal. 
Vessels of dura mater and of pia mater congested. Dura mater adherent to 
bone over right posterior lobe of cerebrum, membranes adherent to pia mater 
over left middle lobe of brain. General moderate opalescence of the arach- 
noid. Other organs in remarkably good condition. 

The entire brain was at once sent to me in a solution of bichromate of po- 
tassa, and I made a careful examination of it in a few days. 

The only externally visible lesion is on the left hemisphere. There a patch 
of dura mater adheres to the soft membranes and the brain, at the posterior 
extremity of the third frontal convolution and the lower extremities of the 
ascending frontal and ascending parietal convolutions, bridging over the 
fissure of Sylvius. The patch measures 22 mm. in a vertical direction, and 
15 mm. horizontally. The anterior border of the piece of membrane is 58 
mm. from the apex of the frontal lobe ; its upper edge is 58 mm. below the 
u^per border of the frontal lobe (at the longitudinal fissure) : and its lower 
border, lying on the fissure of Sylvius, is 55 mm. above the lowest part of the 
sphenoidal lobe. 

The arachnoid and pia mater surrounding the patch, in the fissure of Syl- 
vius and for 25 mm. above it, are thickened and whitish. 




CASE III.— PATCH OF PACHYMENINGITIS ADHERENT TO LEET HEMISPHERE. 

The patch lies in a depression in the underlying convolutions, and a hori- 
zontal transverse section through it and the hemisphere shows that the three 
membranes are fused in the patch, which is 2.5 mm. thick, and that the subja- 
cent gray matter of the third and ascending frontal convolutions, and the 
ascending parietal convolutions, are grayish and translucent. 

The same section reveals extensive softening in the central parts of the left 
hemisphere. The lenticular ganglion (extra- ventricular part of corpus stri- 
14 



210 LOCALIZED CEREBRAL LESIONS. 

jitum) is soft and reddish ; contains nervous debris, granular bodies, and 
granular blood-vessels. The few ganglion cells seen are filled with granula- 
tions. 

A second softened spot is in the white centre of the hemisphere, in its pos- 
terior half, outside and above the lateral ventricles. The microscope shows 
the same granular detritus as in lenticular ganglion. Abundant granular 
bodies are also found in the white centre of the frontal lobe, and in the con- 
volutions of the island of Rett, deep in the fissure of Sylvius. 

The corpus striatum proper contains only a few granular ganglion cells. 

Microscopic examination gave evidence of descending degeneration in the 
motor tract through the left half of the pons Varolii and medulla oblongata, 
and the right lateral column of the spinal cord. 

The ganglion cells of the anterior horns of the spinal cord contained an 
abnormal amount of granular matter, and the posterior columns contained an 
immense number of amyloid bodies. 

Kemarks. — This case, partly from its complicated nature, and 
partly because of its imperfect record, is difficult to analyze with 
reference to the question which I have in view in this contribu- 
tion. 

In addition to epileptic, paralytic, and aphasic manifestations, 
there seems to have been actual insanity present, as manifested 
during life by hallucinations and delusions, and by incoherence 
and dementia ; and post-mortem, by opacity of the delicate mem- 
branes of the brain, and degeneration of the posterior columns 
of the spinal cord. 

It seems probable, however, that some of the so-called " de- 
mentia " in the first part of the history of the case was aphasia. 

In estimating the share of the two lesions in the production of 
symptoms it must be admitted that, whereas the patch must 
have been ancient, the ramollissement cannot have been very old. 
The latter lesion was, however, at least six weeks old, since sec- 
ondary descending degeneration had set in to a slight degree. 
Yet, as the chief phenomena of the disease — epileptic seizures, 
transitory hemiplegia, and aphasia — existed from the beginning 
of the illness, it is right to conclude that the older lesion, i.e., the 
localized chronic meningitis, was the cause of these symptoms. 

The thickened state of the pia mater, arachnoid, and dura ma- 
ter acted upon subjacent parts in several ways : by pressure and 
by mechanical irritation, increased by the respiratory and cardiac 
movements of the brain, and by interfering with the blood-sup- 
ply of the gray matter, and of the white substance for a certain 
depth. The part which was most affected by this lesion was 



LOCALIZED CEREBRAL LESIONS. 211 

Broca's speech centre in the posterior part of the third frontal 
convolution. 

Consequently, it seems right to me to consider this case as 
favorable to the hypothesis of the localization of functions in 
limited parts of the cortex of the brain. 

As to the nature of the localized meningitis, nothing is said in 
the history of the case concerning syphilis, or symptoms belong- 
ing to the syphilitic category. Sections of the patch and subja- 
cent nervous tissue were very difficult to make, because of the 
difference of density between the two tissues and the lax bond 
of union between them. The specimens now passed around 
must be judged leniently because of these peculiarities. In so 
far as the thickness of the sections will permit microscopic 
study, it seems to me that the lesion is a simple hyperplastic 
one, having resulted in the formation of dense fibrillar connec- 
tive tissue. In no part of the specimens can I find the numer- 
ous young cells so characteristic of gummatous products. 

Case IV. — Constitutional syphilis, commencing caries of the dorsal 
vertebra', acute tuberculosis; tubercular meningitis, most developed over 
left third frontal convolution and island of Reil ; intermittent apha- 
sia, and later, hemiplegia. 

Mr. X , aged forty-three years ; a private jDatient of Drs. William H. 

Draper and Frank P. Kinnicutt. The latter gentleman has kindly furnished 
me with abbreviated notes of the case, and the brain was placed in my hands 
for examination. 

The patient was a victim of unusually severe syphilitic infection: having 
had series of secondary and tetiary lesions while under Dr. Draper's care. At 
the time of his last illness he had syphilitic neuralgia. In 1874-5 there was 
slight trouble at apex of right lung, but the disease seemed wholly arrested 
during the past year. 

Since two months, emaciation has rapidly advanced, and strength has much 
diminished. Since April 20th there has been fever of a very irregular type; 
the temperature varying from 37.1° to 39.1° C. ; the temperature not being 
the same on any two days. Pulse has been very frequent : 100 to 120. Phys- 
ical examination has revealed simply moderately fine moist rales, at first only 
in the anterior and posterior parts of the right lung; later, during the last 
four weeks of life, in both lungs. 

On May 10th there was suddenly developed aphasia and agraphia, without 
loss of consciousness or jiaralysis. [This negative statement is not made upon 
the patient's or the nurse's statement, but after critical examination by Dr. 
Kinnicutt, whose accuracy in clinical observation is extreme.] This condi- 
tion of aphasia continued about twenty-four hours, and during this time the 



212 LOCALIZED CEREBRAL LESIONS. 

patient's mind was perfectly clear. A nearly complete intermission (return 
of speech) then occurred, followed in twenty-four hours more by a second 
attack of complete aphasia and agraphia, also without impairment of con- 
sciousness or mental clearness, and without paralysis. These intermissions 
and attacks continued to succeed one another until within forty-eight hours 
of death, when the intermissions became incomplete. At first there existed 
only a certain slowness of speech during the intermissions ; but in the last few 
days there was partial aphasia ; or, more properly speaking, aphasia would 
show itself after a few moments of correct speaking. Right hemiplegia was 
almost imperceptibly developed (face and limbs); became marked forty-eight 
hours before death, and was complete, with a semi-comatose state, at the last. 

At no time was there only pain in the head. General hyperalgesia (more 
marked on the right half of the body) was present in last week of life. 

Dr. Kinnicutt diagnosticated acute pulmonary tuberculosis, with a cerebral 
complication. There was a doubt on our minds whether the cerebral lesion 
was meningitis, tubercular or syphilitic, or whether it consisted in syphilitic 
arteritis, involving the left middle cerebral artery. 

The post-mortem examination was made sixteen hours after death, by Dr. 
Kinnicutt, and the following lesions found : 

There was a cavity about two centimeters in diameter, filled with pus, in 
the right half of the body of the twelfth dorsal vertebra; and the pus was 
seen to have made its way within the sheath of the psoas muscle, nearly 
as far as Poupart's ligament. At the apex of the right lung was a dense 
cicatrix, and over one of the lower ribs on the left side the remains of a 
gumma which had suppurated many months. Gray tubercular granulations 
were found in abundance throughout both lungs, in the spleen and kidneys. 
There were none in the liver, and their presence in the peritoneum was 
doubtful. 

The brain, placed in a solution of bichromate of potassa, was at once sent 
down to me for examination. I did not do more at first than note that the 
left sphenoidal lobe had been damaged in the removal of the brain, and that 
there were a very few granulations, the size of tobacco seeds, or a little larger, 
in the pia mater on the convexity of the hemispheres. My reason for not cut- 
ting the brain Avhile fresh was that, from the lack of consistency of the left 
anterior lobe, Dr. Kinnicutt thought it likely that there was an abscess or a 
patch of ramollissanent near the third frontal convolution, and I wished, if 
there were such a lesion, to obtain its exact topography. 

The brain having been completely hardened in bichromate of potassa, I 
proceeded to examine it by means of vertical and horizontal sections. Some- 
what to my surprise, I found no lesion in the deeper parts of the hemi- 
spheres. There was only a leptomeningitis of very peculiar distribution. 

In the first place, the convexity and base, and the whole of the right hemi- 
sphere showed only traces of exudation alongside of the chief vessels of the 
pia mater, with here and there a granulation varying in size from .5 mm. to 1 
mm. in diameter. 

In the second place, the lower median region of the left hemisphere showed 
very much more developed exudation. The vessels covering the posterior 
part of the third convolution as it dips into the fissure of Sylvius were bor- 



LOCALIZED CEREBRAL LESIONS. 



213 



dered by thick bands of exudation quite as wide as the vessel itself, and the 
pia mater was thickened over a sj^acc 25 mm. or more in diameter. On open- 
ing the fissure of Sylvius, the pia lying in it was found, enormously thickened, 
and its meshes filled with semi-solid and solid exudation. 





-A. SHOWING FOCUS OF TUBERCULAR MENINGITIS ON EXTERNAL FART OF LEFT HEMI- 
SPHERE. B. THE EXUDATION IN THE FISSURE OF SYLVIUS. 



The focus of the meningitis was in the territory of distribution of the left 
middle cerebral artery, especially over the third frontal convolution, and 
the convolutions of the island of Reil. 

Microscopic examination of the exudation showed an accumulation of young 
cells in the meshes of the pia mater, and more especially round about blood- 
vessels next the cortex. Around many of these the exudation formed tumor- 
like swellings, or, more exactly speaking, muff-like masses. The young cells 
could be followed some distance into the cortex of the brain, lying in the 
perivascular spaces. This examination corroborates the diagnosis of tuber- 
cular meningitis. 



214 



LOCALIZED CEREBRAL LESIONS. 



PART II. 

CASES IN WHICH A LIMITED CEREBRAL LESION CAUSED PARALYSIS. 

Case Y. — Limited softening of the left ascending frontal convolu- 
tion ; right hemiplegia without aphasia. 

A female, aged fifty-four years, was admitted to my ward in the Epileptic 
and Paralytic Hospital on Blackwell's Island, on June 20th, 1875. 

The brief history of her case is to the effect that about Christmas, 1874, 
during the night, she was suddenly paralyzed on the right side. She did not 
lose consciousness, her face was not paralyzed, and speech was preserved. 

Examination shows that patient's face is not paralyzed, her tongue points 
straight, the right upper extremity is palsied, but there is slight voluntary 
motion at elbow and fingers. The lower limbs are without voluntary motion. 
There is some oedema about the ankles, and a superficial bed-sore on both 
nates. Death occurred June 23d. 

Post-mortem examination. — The only externally visible lesion in the brain 
is a disappearance of a part of the convolution in front of the fissure of Ro- 
lando, within 25 mm. of the great longitudinal fissure, on the left hemisphere. 
It is not like a yellow patch, but is more like an ulceration of the convolution. 
A horizontal section, made through the hemispheres above the ventricles, 
shows healthy tissue in the right hemisphere, while in the left it reveals a 
softened but not much discolored part in connection with the superficial le- 
sion above described. A vertical transverse section through this lesion and 
the lower part of the left hemisphere shows that the softened mass has its 
greatest diameter vertically, and extends from the roof of the lateral ven- 
tricle upward. 




CASE V.— 'LIMITED SOFTENING OF THE LEFT ASCENDING FRONTAL CONVOLUTION. 

No other lesion is found in the cerebral tissue. The cerebral arteries show 
some arteritis, especially the left middle cerebral; but their channels are 
open. 

A considerable spinal lesion is found, consisting of purulent infiltration of 
the lower cervical muscles alongside the 3d, 4th and 5th vertebras. On re- 
moving the posterior portion of the vertebra), there is found a thick exuda- 



LOCALIZED CEREBRAL LESIONS. 215 

tion, like a membrane, between the dura mater and the bones. Between tne 
dura mater and the bodies of the vertebrae there is no trace of exudation. 
The arachnoid and the spinal cord seem healthy. The only osseous lesion is 



This case is only to be made use of with reservation, because 
of its imperfect history, and because of the co-existence of a 
spinal peri-pachymeningitis. The main interest of the case is a 
negative one of unquestionable exactness. At no time was there 
aphasia ; and it may be seen that the softened patch was placed 
quite far from the speech centre, above and behind it. It would 
seem that the face and tongue were not palsied ; and this again 
is in accord with the location of the lesion, which is in the 
ascending frontal convolution, near Terrier's centre, No. 6, which 
he * finds in the monkey to co-ordinate certain movements of 
the arm and forearm. 



PAET III. 

CASES IN WHICH LOCALIZED CEREBRAL LESIONS GAVE RISE TO 
LOCALIZED. CONVULSIONS OR SPASM. 

Case VI. — Injury to the top of the skull on the right side, osteitis, 
inflammation of the dura mater, with lesion of subjacent convolutions ; 
development of a large sarcomatous tumor in the right hemisphere ; 
epilepsy ; spasms limited to left arm, neclc, and face; left hemiplegia ; 
no neuro-retinitis. 

George S., a laborer, was admitted to my service in the Epileptic and 
Paralytic Hospital, Blackwell's Island, on April 19, 1875, for epilepsy. 

The following history of his case was obtained : 

On December 19, 18G9, he got out of bed, in the middle of the night, to 
get some water ; went to a stairway on the outside of the house, made a mis- 
step, and fell to the ground. He lay insensible until morning, when he was 
taken care of. Paralysis of the left side followed the injury, but improved 
under treatment sufficiently to allow him to do his ordinary work. 

Three years later (1872), he was seized with epileptic convulsions of the 
common typical sort : sudden fall, general spasm, biting of tongue. These 
attacks ceased in December, 1874, and were then wholly replaced by very 
frequent attacks of partial or localized epilepsy, without loss of consciousness. 

These attacks consist of tonico-clonic spasm of the muscles of the left side 
of the face and neck, and of left upper extremity, especially the thumb and 

* The Functions of the Brain. New York, 1876, p. 306. 



216 LOCALIZED CEREBRAL LESIONS. 

index. The left upper extremity is strongly flexed and the mouth drawn to 
the left during the attack, which lasts from 80 to 140 seconds without nitrite 
of amyl, and from 70 to 90 seconds with it. The attacks occur with extreme 
frequency, from three to eleven taking place every hour. At night they are 
rare. The spasm begins simultaneously in the facial muscles and in those 
governing the thumb and index. Consciousness is never lost. No general 
convulsions occur. An examination shows the left pupil to be a trifle larger 
than the right ; the left cheek is paretic ; the left arm and forearm absolutely 
paralyzed, and the left leg weak. The gait is characteristic of hemiplegia. 
There is marked tactile anaesthesia on the left side ; the two points of an 
cesthesiometer not being distinguished at 45 mm. on the forehead, at 40 mm. 
under the eye, at 40-50 mm. on the side of the cheek and on the fingers. He 
feels pricking normally on the face and fingers. 

The injury to the skull, caused by the fall in 1869, is indicated by an irreg- 
ular depression existing on the vertex, within an inch to the right of the 
median line, in a plane passing vertically through the external auditory 
meatus. 

The attacks of limited epilepsy were much reduced in frequency, but not 
interrupted for any length of time by the systematic use of the bromides 
pushed to the limit of prudence. The partial hemiplegia increased. 

June 28th. — The weakness of the left leg has greatly increased ; patient is 
unable to stand or walk without help ; the fingers can be moved a little, and 
a degree of contraction has appeared in the elbow and hand. 

Sept. 13th. — Patient had a slight general convulsion, with loss of conscious- 
ness, last night. 

December 3d. — Is growing gradually worse. The ophthalmoscope shows 
fullness of veins, but no neuro-retinitis. Patient lies on his back, with left 
arm strongly flexed ; there is some opisthotonus ; complains of being deaf in 
right ear. Axillary temperature 36.4° C. 

December "7th. — Complains of pain in right arm and leg, and in posterior 
part of head on the right side ; pupils arc equal and of medium size. There 
is no distortion of face, and the tongue comes out straight. The left upper 
extremity is completely paralyzed ; the forearm and hand flexed and rigid. 
Left lower extremity is deprived of voluntary power, and lies rigidly extended. 
The neck is rigid, with tendency to opisthotonus. During the examination 
(and at other times) patient turns his head and eyes away from the palsied 
side — deviation conjuguee. Contact and pinching are felt on the jmlsied side. 
Pinching produces reflex spasm in the left limbs, of the nature of spinal 
epilepsy, i.e., tonico-clonic spasm. The veins of the neck and forehead, 
especially on the right side, are unnaturally distended. An ophthalmoscopic 
examination shows no neuro-retinitis. Pulse 108, axillary temperature 
37.1° C. 

Localized and general convulsions recur from time to time. Patient is 
semi-conscious. 

Death occurred on December 23, 1875. 

The body is much emaciated, and rigor mortis is well marked, especially on 
the left side. On removing the scalp there occurs a large escape of blood 
from enormously distended veins. The occipital veins on the left side are 



LOCALIZED CEREBRAL LESIOXS. 217 

just perceptible, while on the right side they arc G mm. in diameter. The 
frontal veins on both sides are much developed, but not rilled with blood, 
because the body has lain upon its back. The right frontal bone is the seat 
of marked irregularities, and is rough and fissured between the median line 
and the external angular process. On the top of the skull, on a line passing 
vertically in front of the external auditory meatus, and 12.5 mm. from the 
median line, are two depressions about the size of peas. One of these con- 
tains a varicose vein, and a sound passed through the aperture seems to strike 
against the dura mater. 

After sawing the skull through in the usual manner, the brain is divided 
horizontally without removing the skull-cap. The inferior half of the brain, 
examined as it lies in the fossa? of the skull, presents the following peculiari- 
ties : The right half of the brain is much enlarged, and the lateral ventricle 
and septum lucidum are forced over to the left. On the left side, the corpus 
striatum, thalamus, and convolutions appear healthy. On the right side the 
intra-ventricular nucleus of the corpus striatum alone is normal. Its extra- 
ventricular nucleus is undistinguishable. The white matter forward and out- 
side of the corpus striatum, and in the neighborhood of the optic thalamus, 
is of a creamy consistency. The external and posterior half of the thalamus 
is involved in this softening. The convolutions directly outside of the thala- 
mus are very much crowded together. At the base of the brain the convolu- 
tions lying immediately over the right olfactory bulb are very much softened, 
as are also the convolutions of the right sphenoidal lobe. The inferior con- 
volutions of the occipital lobe appear normal. The white matter of the apex 
of the right anterior lobe is so soft that it is torn through in removal. 

The upper half of the cerebrum, still lying in the skull, appears as follows : 
The septum lucidum is displaced to the left of the median line fully one-half 
inch. The white substance of the right hemisphere is the seat of a tumor, 
larger than a lien's Qgg. movable in the substance of the hemisphere, and of 
theconsistence of glandular tissue. The opto-striate bodies of the right side 
are strongly compressed by the tumor, and so are the convolutions of the 
parietal region. The white matter in front and behind the growth is softened. 

The upper half of the brain is carefully detached from the calvarium. by 
pushing the fingers between the dura mater and the bone. Xo difficulty is 
experienced in doing this until the neighborhood of the external depression 
in the bone is reached, when the dura mater is felt to be strongly adherent to 
the skull. TTith some difficulty the adhesion is broken up and the brain 
removed. 

A careful examination of the convexity of the brain, thus exposed, shows 
the dura mater depressed and firmly adherent to the convolutions on the 
right side of the longitudinal fissure. There is some bony formation in the 
depressed adherent part of the dura. Around the patch, which is 25 mm. in 
diameter, the dura mater is moderately adherent to the anterior lobe over an 
oval space, measuring 75 mm. longitudinally, and 38 mm. transversely from 
the median line. The longitudinal fissure opposite this patch is obliterated 
by adhesions, and these are also present 13 mm. to the left of the median line. 

Just to the right of the median line, opposite the depressed adherent spot 
in the dura, the skull presents a marked thickening and roughness. This 



218 



LOCALIZED CEREBRAL LESIONS. 



tumor-like development of bone is 25 mm. anterior to the opening in the skull 
above described. A transverse section of the bone at this point shows it to 
be 13 mm. thick, and much condensed. 

A 




CASE VI.— PATCH OF THICKENED DURA MATER ON TOP OF RIGHT HEMISPHERE. 

Transverse sections through the pons Varolii show no lesion except hyper- 
emia. 

The fossae of the skull are unusually deep, and irregularly furrowed and 
hilly. 

The upper half of the left hemisphere, after hardening in bichromate of 
potassa, is examined by means of vertical transverse sections. The surfaces 
of these sections show that the tumor is very much larger than would appear 
from an inspection of the convexity of the hemisphere, or of the horizontal 
section above the ventricles. In fact, almost the whole of the anterior two- 
thirds of the upper half of the right brain is occupied by the growth, which 
has partly pushed aside and partly taken the place of the nervous tissue. 




CASE VI. — TRANSVEESE VERTICAL SECTION THROUGH HEMISPHERES, SHOWING RELATIVE SIZE AND 

POSITION OF THE TUMOR. 



A transverse vertical section made through the anterior third of the thick- 
ened patch of dura mater reveals that the tumor occupies the whole thickness 



LOCALIZED CEREBRAL LESIONS. 219 

of the hemisphere above the opto-striate bodies, and that these bodies are 
strongly pressed upon. The mass of the tumor is so considerable as to press 
upon the inner surface of the left hemisphere. 

A transverse vertical section through the middle of the thickened patch of 
dura mater and the corebrum shows an appearance represented in Fig. 2. 
The tumor, continuous with the dura mater, extends deeply into the sub- 
stance of the right hemisphere, down to the level of the roof of the lateral 
ventricle. Besides, this roof and the falx cerebri are much displaced by the 
growth. 

Posterior to this level the tumor diminishes rapidly in size, though still 
pushing over to the left of the median line. 

A transverse vertical section made in the hinder part of the brain (beyond 
diseased dura mater) shows the tumor only as a small nodule in the upper 
inner part of the section-surface, lying wholly in the white substance. 

The great longitudinal sinus is obliterated for a space of nearly 50 mm. in 
the thickest part of the patch of dura mater. 

Microscopical examination showed the tumor to be an alveolar 
sarcoma in parts, and in others a common sarcoma. 

As regards the connection between these lesions and the 
symptoms during life : 

These symptoms were at first epilepsy, for nearly two years, 
followed by partial hemiplegia on the left side of the body, by 
incomplete localized epileptiform spasms in the left cheek, neck, 
and upper extremity, and the scene closed with complete left 
hemiplegia and a few general epileptic attacks. 

It seems right to me to connect the above symptoms with the 
lesions in the following manner : 

The first manifestations, general erjileptic seizures, were 
caused by the development of thickening of the skull (internal 
plate), inflammation of the dura mater, and irritation of the 
cerebral substance. 

As the pachymeningitis increased, with formation of bony 
spicules in its substance, the inflammation extended along the 
pia mater farther outward and backward, and thus reached parts 
of the convolutions which lie next to the fissure of Rolando and 
above the upper end of the fissure of Sylvius. These parts 
cover the regions numbered 2, 3,4, and 6, in Ferrier's chart of 
the probable motor centres in the human brain, as deduced from 
experiments on apes. 

By this irritation, there were caused the peculiar spasmodic 
movements of the muscles on the left side of the face and neck 
and of the left hand and arm. Ferrier considers the regions 



220 LOCALIZED CEREBRAL LESIONS. 

numbered 2, 3, 4, and 6, as motor centres for the hand and arm 
chiefly. 

There was also partial left hemiplegia. Later still, sarcoma 
was developed from the pachymeningitis ; the malignant growth 
rapidly extended in all directions, substituting itself for the 
nervous tissue, and producing powerful compression-effects in 
all directions, but chiefly downward upon the opto-striate 
bodies. 

In this terminal stage of the disease, the phenomena were 
complete left hemiplegia, a few general convulsions, no localized 
spasm. 

As an additional sign of extensive lesion of the hemisphere, 
we may note the conjugate deviation of the eyes, away from the 
paralyzed side, and toward the injured hemisphere. 

Why, with such an enormous tumor, and such an increase of 
intra-cranial pressure as must have existed, there was no am- 
blyopia, neuro-retinitis, atrophy of the optic nerves, diplopia or 
hemiopia, is a very puzzling question. This case is the second 
one of large cerebral tumor without choked disks or atrophy of 
the optic nerves which I observed in 1875. 

In conclusion, I think that this case may be looked upon as 
corroborative of Hughling Jackson's, and Ferrier's theory of the 
existence of excitable motor districts, in some way connected 
with the motions of the face and forearm, in the upper median 
convolutions of the cerebrum — the ascending frontal and ascend- 
ing parietal convolutions. 

Case YII. — Pneumo-pyo-thorax ; suppurative cerebral meningitis; 
abscesses in both hemispheres; localized epileptiform spasms in left 
hand, arm, and face ; no paralysis or aphasia. 

For notes of the following remarkable case I am indebted to my friend, Dr. 
F. P. Kinnicutt. 

The patient, a lad of thirteen, had been under the care of Drs. William H. 
Draper and Kinnicutt for empyema during several years. 

During the last year of his life, the patient had a number of attacks of 
what was called slight septicaemia, characterized by moderate chill, fever, and 
diminished secretion from the pectoral fistula. The checking of the outflow 
of pus was held to be the cause of these attacks. 

On February 18th, 1877, there occurred a severe chill, followed by fever, 
with a temperature of 37.7° and 38.8° C, lasting forty-eight hours. There 
was severe diffused headache. Dr. Kinnicutt was called and made the 
following- observations : 



LOCALIZED CEREBRAL LESIONS. 221 

On February 23d, patient felt very well, and it was thought that this attack 
had terminated favorably, like the others. But suddenly, while engaged in 
play, there occurred a twitching in the middle finger of the left hand ; the 
spasm soon extended to the forearm. The entire spasm (clonic in form) only 
lasted a few seconds, and rather amused the boy. A few hours later a second 
attack took place, and was witnessed by Dr. Kinnicutt. Patient was aware 
of beginning of spasm by an almost imperceptible tremulousness of the facial 
muscles on the left side, followed, a few seconds later, by clonic spasm of the 
left middle finger and thumb (the former being strongly flexed, the latter 
adducted and flexed), succeeded by clonic flexions of the forearm, and evident 
clonic spasm of the left side of the face. The entire seizure lasted about 60 
seconds, and during it there was no spasm of any part but the left face, arm, 
forearm, and fingers. There was no loss of consciousness, and patient con- 
versed intelligently during the attack. The pupils and vision remained normal. 
Not a trace of local or general paralysis followed the spasm (contrast to 
Hitzig's case). There was no anaesthesia or abnormal sensation (aura or 
numbness) in the affected parts before, during, or after the attack. 

The headache, of which he has complained since the 18th, has grown much 
worse ; it is not localized, but is more violent in the occipital region ; the 
pain extending into the nape of the neck. 

There were five or six of these hemiplegic spasms on the 23d. 

I saw the patient in consultation with Dr. Kinnicutt that evening, and a 
careful examination failed to reveal any objective symptom except a buccal 
temperature of about 37.7° C. The pulse was proportionately rapid, but not 
irregular. Complaint was made of severe headache, as above. No trace of 
paralysis or disorder of sensibility ; no nausea ; mind remarkably clear ; 
patient not anxious. Ophthalmoscope shows only somewhat enlarged retinal 
veins. 

I agreed with Dr. Kinnicutt in diagnosticating a meningitis, probably of a 
tubercular nature ; and I advanced the view that there was a lesion of the 
convolutions on the right side, in the neighborhood of the fissure of Sylvius, 
involving the excitable district of the cortex, and producing the localized 
epilepsy. 

February 2A.th. — At 6 o'clock a.m., had a general convulsion, followed by 
vomiting ; T. 37.1°, P. 108 and regular. At 2.30 p.m., T. 38.8°, P. 100 ; 
headache violent ; vomited once. At 10 p.m., T. 38.5°, P. 100, regular ; R. 
32 and regular. 

February 2oth.—At 10.30 a.m., T. 39°, P. 100, regular. At 5 p.m., T. 38.5°, 
P. 100, regular. At 10 p.m., T. 37.7°, P. 100. Vomited twice during after- 
noon ; no new symptoms ; headache violent ; urine albuminous. 

February 2Qth.— At 10 a.m., T. 39°. At 3.15 p.m., T 37.7°, P. 94, slightly 
irregular. At 10.30 p.m., T. 37.5°, P. 88, slightly irregular. Vomited once 
in twenty-four hours. 

February 27th.— At 2.30 p.m., T. 37.5°, P. 80, R. 20. At 10 p.m., T. 38°, 
P. 88, irregular, R. 16-20, irregular. 

February 28th. — At 5.30 A.M., pain in head intense ; no motor disturbance 
of any kind ; pupils normal and symmetrical ; pulse and respiration irregular, 



222 



LOCALIZED CEREBRAL LESIONS. 



the latter exhibiting the Cheyne-Stokes phenomenon typically. The mind is 
perfectly clear ; strength good. 

At 6 a.m., there occurred ;i general convulsion, followed by several others 
in rapid succession. There was loss of consciousness, and death took place 
quietly at 7.40 A. m. 

The treatment employed by Drs. Draper and Kinnicutt consisted in blisters 
to the neck, the giving of iodide of r>otassium, and, at last, to alleviate the 
severe cephalalgia, morphia hypodermically. 




CASE VII. — ABSCESS IN LOWER PART OP SECOND PRONTAL CONVOLUTION, LEFT SIDE : NO SYMPTOMS, 



I made the post-mortem examination at 3 o'clock p.m. on March 1st, in the 
presence of Drs. Draper and Kinnicutt. The condition of the left lung and 
remains of the pleura was one of great interest, but details on this point 
would here be out of place. 

As regards the encephalon, we found a meningitis most marked at the 
base and sides of the brain, with purulent exudation in the meshes of the ])ia 
mater. There were no tubercles to be seen, and no marked lesion was to be 
found on the surface of the right hemisphere. On the left side, however, on 
the anterior lobe in front of the fissure of Sylvius, was a softened spot, prob- 



LOCALIZED CEREBRAL LESIONS. 



223 



ably an abscess. On carefully slicing the brain, a second lesion was found, 
however, and that in the right hemisphere just above the posterior extremity 
of the fissure of Sylvius. It is well worth while to state j^recisely the location 
and limits of these two localized lesions. 




CASE VII.— ABSCESS IN RIGHT SECOND FARIETAL CONVOLUTION 

HAND AND FACE. 



CAUSE OF SPASM IN LEFT 



The first abscess, measuring 2 cent, in diameter, and lined by a soft mem- 
brane nearly 1 mm. thick, lay in the lower part of the second frontal convo- 
lution, and the anterior border of the third frontal convolution, on the left 
side, just in front of the speech-centre which has been referred to as injured 
in the cases of aphasia recorded in this essay. I am prepared to state, most 
positively, that the posterior part of the third convolution and island of Reil 
were perfectly healthy to the naked eye. The injured part is quite in front of 
Ferrier's centre No. 9. 

During life, no symptoms, motor, sensory, or intellectual, oc- 
curred which might be connected with this large irritating and 
destructive lesion. Consequently, it seems to be fair to con- 
clude that in some human brains the lower part of the second 



224 LOCALIZED CEREBRAL LESIONS. 

frontal convolution is not excitable, and contains no motor cell- 
groups. 

As regards the second abscess, not larger than a pea, it was 
found wholly in the white substance just beneath the cortex of 
the anterior part of the second parietal convolution on the right 
side, just above the upper extremity of the fissure of Sylvius. 
This lesion, which, in all probability, gave rise to the spasm in 
the left face and hand, is placed just behind the parts which 
Ferrier considers to bo centres for motions of the hand and 
wrist. 

If any conclusion is to be drawn from a study of the second 
lesion, it is that in man fibres for the face and hand pass farther 
downward and backward in the hemisphere than would be indi- 
cated by experiments on dogs and apes. 

A fact certainly well worthy of remark is, that a small lesion 
in an excitable district of the brain may produce well-marked 
symptoms, whereas a much larger lesion may exist in non-ex- 
citable regions without giving any sign of its presence. 

Conclusions. — The three cases in Part I. fully bear out 
Broca's (and Ferrier' s) hypothesis of the existence of a speech- 
centre in the posterior part of the left third frontal convolution, 
and in the anterior folds of the island of Reil. 

The case in Part II. is unfortunately worth very little ; still 
it may serve to show that a lesion of the ascending frontal con- 
volution may cause paralysis of the arm (and leg) without affect- 
ing the lingual and facial muscles, or producing aphasia. 

The two cases in Part III. appear to indicate that spasm, lim- 
ited to one side of the face and one upper extremity, may be set 
up by irritation of quite distant parts of the cerebral cortex, ex- 
tending from region No. 5 to below region d, in Ferrier's chart. 
In this particular, these cases, while not contradicting experi- 
mental results, show that if there be such motor centres in man, 
they are not distributed quite as in monkeys and dogs. 

The only case which appears to bear against the doctrine of 
localization of motor functions in the cerebral cortex is Case I. 
In this, it will be remembered, great recovery of voluntary power 
occurred, although a large part of the cortex of one hemisphere, 
including regions 6, 7, 11, a, b, and c, of Ferrier's chart, or, in 
other words, the so-called psycho-motor centres for the hand and 
forearm, the angle of the mouth and platysma, and those for the 
hand and wrist, were irreparably injured, nay destroyed. 



LOCALIZED CEREBRAL LESIONS. 225 

I append a reproduction of Ferrier's chart of psycho-motor 
centres to render easy the determination of the injured parts in 
the above cases. 




ferrier's chart— 1, Centre for Leg; 2, 3, 4, for Arms and Legs; 5, Extension of Arms and 
Hand ; 6, for Biceps of Arm ; 7, 8, for Angle of Mouth ; 9, 10, for Lips and Tongue (Broca's 
Centre) ; 11, for Platysma ; 12, for Head, Eyes, and Pupils ; a, b, c. d (Ascending Frontal Con- 
volution), for Hand and Wrist ; 13, 13', 14, Centres for Vision and Hearing. 

The problem of localization of functions in the cerebral cortex 
is a grand one, and well worthy of thorough study. I am not 
prepared to accept the hypothesis as enunciated by Ferrier, yet 
it seems to me in the highest degree rash and unscientific to call 
it baseless and worthless, because a few recent negative cases can 
be brought forward against it. As for old cases bearing on these 
questions, I wholly reject them as cracked or weak links in a 
chain that must be made only of approximately perfect joints. 
It is surely the duty of all medical men to publish cases nega- 
tively or positively bearing on this question, but only when 
their observations have been made in an exact manner. 

With a large accumulation of precise autopsies, with careful 
experiments by physiologists, with more embryological knowl- 
edge, and with unbiased comparative anatomy, some one may, 
in a few years, study and solve the problem. 
15 



THE ABUSE AND USE OF BEOMIDES * 

Mr. President and Gentlemen : The time allowed by cusies* 
for the reading of a paper before a medical socfeiy will not per- 
mit me to treat the subject of the abuse and use of bromides as 
fully as its importance deserves. I shall only be able to con- 
sider the salient points of the topic, almost restricting myself to 
what I have observed in this branch of therapeutics. 

The paper will consist of two parts. The first devoted to a 
study of bromism, or intoxication by the bromides ; the second 
to a succinct statement of my own method of using the bromic 
salts in the treatment of epilepsy and other neuroses. 

Bromine (from fiptijuos, a bad smell,) was discovered in 1826 
by a French chemist, Balard, and to him we also owe the pro- 
duction of the bromide of potassium. 

Bromide of potassium appears to have been soon tried by 
physicians, but it was not until 1840 that its physiological and 
true therapeutical effects were first apprehended. This was by 
a German, Otto Graf/f- 
in 1850 Huette4 of Paris, read to the Societe de Biologie a 
remarkable paper, which may be considered as the basis of the 
modern use of the bromides. Huette observed and accurately 
described the general sedative effect of the bromides, their de- 
pressing action upon the sexual organs, the anaesthesia of the 
palate and throat, the mental torpor, the disorders of mobility, 
and the cutaneous anaesthesia produced by the drug. He also 
determined (against a number of physicians) its uselessness in 
late syphilis. Huette may, consequently, be rightly considered 
as having been the first to describe mildbromism. 

"With respect to the use of bromides in neuroses, and espe- 
cially in hysteria and epilepsy, it is generally admitted that Sir 

* From the Journal of Mental and Nervous Disease, July, 1877, vol. ii. Read 
before the New York Medical Journal Association, April 25, 1877. , 

f De Kali bromati efiicacitate interna experimentis illustrata. Lipsiae, 1840. 
(From Voisin's Essay.) 

% Recherches sur les proprietes physiologiques et therapeutiques de bromure de 
potassium. Mem. de la Societe de Biologie. 1850, vol. ii., p. 19. 



ABUSE AND USE OF BROMIDES. 227 

Charles Laycock * was its originator and advocate, and that 
Brown-Sequard did the most to systematize and render success- 
ful the bromic treatment of epilepsy. For further historical 
considerations I would refer to Auguste Yoisin's excellent essay 
published in 1875. t 

From this time (1857) the bromides have been used by an 
increasing number of physicians in an almost endless list of dis- 
eases and symptoms. Among these may be mentioned Hysteria, 
Epilepsy, Infantile Convulsions, Puerperal Convulsions, Sexual 
Excitement, Chorea, Tetanus, Delirium Tremens, Insanity of 
active form, Melancholia, Cerebral Excitement and Insomnia, 
Somnambulism, Vomiting, Headache, Diabetes, etc., etc. 

This general use of the various bromides (of potassium, 
sodium, ammonium, lithium, camphor, etc.) was largely em- 
pirical, the medicine being prescribed because of its quieting 
effects, and without strict regard to its physiological action. 

From 1867 to the present time numerous researches upon the 
effects of bromides upon the healthy organism have been made 
by competent observers in various countries,^ and since the pub- 
lication of these papers there has been, I believe, a more rational 
and moderate use of bromic salts. 

The most important conclusions reached by these physiolo- 
gists respecting the modus operandi of the bromides, are two in 
number. According to some (Brown-Sequard, Amory), the 
bromides act by causing contraction of arterioles and conse- 
quent diminution in the amount of blood in the nervous centres ; 
while according to others (Eulenburg and Gutmann, Laborde, 
Wood), they affect the nervous tissues directly. All agree, how- 
ever, in considering the physiological result of the action of the 
bromides to be lessened irritability of the nervous centres, 
especially in the motor tract. 

I cannot, of course, now enter upon a discussion of this ques- 
tion, which is really only one phase or face of one of the great- 
est questions in medical philosophy, viz., whether biological 
processes are more dependent upon vascular (vaso-motor and 
hsemic) changes, or upon varying degrees of cellular activity, 

* The Lancet. 1857, i. , p. 528. 

f De l'emploi de bromure de potassium dans les maladies nerveuses. Paris, 
1875. 

% For resume of physiological action consult H. C. Wood's Treatise on Thera- 
peutics. Philadelphia, 1874, p. 278, et seq. 



228 ABUSE AND USE OF BROMIDES. 

but I may be allowed to give it as my opinion that the bromides 
act mainly in the second way referred to, viz., by an action upon 
the anatomical elements (ganglion cells, chiefly) of the central 
nervous system. This belief is based upon physiological experi- 
ments in animals, clinical observations in man, and largely, also, 
by the phenomena of bromism ; which last are, it seems to me, 
quite inexplicable by the first or vascular theory of the action 
of bromides. 

Chiefly, in consequence of the prevalence of the empirical 
notion that the bromides are called for whenever there is excite- 
ment, and partly, also, because of the extreme application of 
certain theoretical views concerning the physiological and path- 
ological importance of changes in the amount of blood in the 
brain and spinal cord, there has been, and is still, I believe, a 
great abuse or overuse of the various bromides, and it is not 
seldom that we meet with patients who have been kept in a con- 
dition of impaired nutrition and nervous atony for months or 
years, by means of these medicines, and with others (less numer- 
ous) who present the toxic symptoms of the drugs, who have 
bromism, so-called. 

The remarks which follow upon the abuse of the bromides, 
are naturally divisible into three sections : 1, concerning the 
general description of mild and of severe bromism ; 2, respecting 
the complication which bromism may cause in diagnosis ; and 3, 
with reference to the legal aspects of bromism. 

I. Bromism of varying degrees. — In a number of cases I have 
observed the following symptoms superadded to legitimate 
symptoms of disease : general debility, with weak pulse and 
coldness of the extremities ; a tendency to stupor ; slight difficulty 
in speaking, partly due to an aphasiform state ; the bromic 
breath and acne. These persons were weak, anaemic individuals, 
who had been given the bromides for the relief of certain head 
symptoms, which were quite gratuitously supposed to be due to 
cerebral congestion. In some of these cases moderate doses of 
the drug had been taken for long periods of time, with frequent 
temporary relief to some symptoms. Yet all the while the 
patient's general condition had been kept below par, in spite of 
tonics and selected food. I have observed the same mild 
bromism, without any real improvement, in some cases of hys- 
teria and hystero-epilepsy. Again, in melancholia, a disease 
in which cerebral nutrition is quite surely lowered and perverted, 



ABUSE AXD USE OF BROMIDES. 229 

I have known injurious effects follow the prolonged use of bro- 
mides. In addition to the instances enumerated, there is a large 
class of patients who, without having any definite disease, suffer 
from nervousness, imperfect sleep, queer sensations about the 
head, and who constantly over-estimate their symptoms, and to 
whom the physician or druggist says, in an off-hand manner, 
" take a little bromide." 

It may be said that often the giving of the bromides in the 
above manner does not produce positive ill effects ; but to this I 
would reply, first, that from what we know of the jnhysiological 
effects of the bromides, such dosing must produce a general de- 
pression, or lowering of vitality, which few patients can tolerate ; 
and, second, that, on general principles, physicians are in duty 
bound to give no superfluous or non-indicated drug to their 
patients. 

Bromism may be much more severe than depicted in the 
above statement ; it may attain the dignity of a distinct morbid 
state, with a clear symptomatology, a well-known course, and I 
am disposed to think, a central lesion. Huette, in 1850, gave a 
partial picture of this severe intoxication, and Prof. William A. 
Hammond has furnished us with a fuller representation of all its 
graver details.'"" 

The chief symptoms of this condition are : 

Cerebral : there is a gradually increased stupor, and dullness 
of intellect ; language is impaired ; failure of memory and dim- 
cult articulation ; the memory is much weakened generally, hal- 
lucinations, delusions, and even delirium may supervene. 

Spinal : general debility becomes marked paresis, and a 
staggering gait, like that of an intoxicated person, is develojDed ; 
the facial and other muscles are tremulous ; the reflex functions 
of the palate and throat are abolished ; general cutaneous and 
mucous sensibility is much dulled ; the pupils are wide and 
sluggish ; the facial expression idiotic or maniacal ; the menses 
reduced or arrested ; the virile power reduced, etc. 

Yaso-motor and trophic : the heart beats feebly ; the arteries 
carry less blood and show less impulse ; the peripheral circula- 
tion is sluo-oish and the extremities cold ; the breath is foul and 
quite characteristic ; the skin of the face and body is covered 
with acne ; the skin and mucous membranes are dry ; the saliva 

* On some of the effects of the bromide of potassium \dien administered in large 
doses. Quarterly Jour, of Psychological Medicine, iii., 1869, p. 46. 



230 ABUSE AWD USE OF BROMIDES. 

scanty and sticky ; sometimes ulcers or a rupia-like eruption 
shows itself on the extremities. 

These symptoms may be so aggravated as to simulate demen- 
tia, mania, or general paralysis of the insane ; and even death 
may ensue from extreme debility. 

I desire particularly to insist upon the resemblance between 
bromism and general paralysis of the insane. In both we ob- 
serve tremor of the facial and lingual muscles, producing a pecul- 
iar vibratory speech ; in both there is an uncertainty in the 
performance of certain movements, as walking or using the hands 
for fine work ; in both there is a failure of intellectual force and 
of memory. Even somewhat exalted notions may be present in 
bromism, though* this is rare. In general paralysis we have 
other important symptoms, such as contraction and inequality 
of the pupil, sexual excitement, peculiar epilejDtiform seizures, 
remarkable remissions in the symptoms, and often good physi- 
cal health, with tense arteries ; all these symptoms being want- 
ing in bromic intoxication. Severe bromism is, I am happy to 
say, very seldom produced, except during the early stage of the 
treatment of obstinate epilepsy,' chiefly for the reason that the 
doses given for other affections are insufficient to bring about 
such a result, in the majority of persons. Dr. Hammond believes 
that bromism is rarely produced by doses less than 2.-3. of the 
bromide of potassium daily, and my experience would lead me 
to a similar estimate. 

Occasionally we deliberately produce severe bromic intoxica- 
tion. This is done in some severe cases of epilepsy, though even 
in these we seldom go farther than creating a state intermediate 
between the two conditions I have described. Again, bromism 
has been proposed as a cure for the morphine habit, or mania. 
Dr. Geo. M. Schweig,* of New York, has published a most in- 
teresting case in illustration of this procedure. The medication 
is certainly very heroic ; but it is doubtful if any treatment not 
imminently dangerous to life, is not acceptable in such a terrible 
malady as the opium habit. Dr. Schweig's paper is, further- 
more, an admirable study of the severe effects of the bromides. 

II. Bromism as a complication in diagnosis. 

The following case is related by Voisin.t 

•• Cure of the Morphine Habit. New York Medical Journal, May, 1876, p. 495. 
f Op cit. p. 68. 



ABUSE AND USE OF BROMIDES. 231 

A patient who had been under treatment for epilepsy became, as his physi- 
cians thought, insane, and was sent to Paris to consult Yoisin. The patient 
was found at a hotel in a state of violent mania, beset by frightful hallucina- 
tions of hearing, and shouting loudly. Later there was stupor, loss of mem- 
ory, of affection, and of appetite ; the walk was oscillating, and all move- 
ments were irregularly performed. Titillation of thenaresand throat showed 
complete loss of reflex action, the hands were tremulous, and the facial and 
lingual muscles were the seat of fibrillary contractions. The pupils were equal, 
and the symptoms had developed very acutely after the use, during some 
months, of potassium bromide in doses of 6.-8. The medical officers of an 
asylum in which Yoisin placed this patient thought he was mistaken in his 
diagnosis of bromism, and in his favorable prognosis ; they looked upon the 
case as one of general paralysis of the insane. 

In a Aveek after the cessation of the bromides and the use of vapor baths, 
purging, black coffee, etc., the symptoms subsided, and in thirteen days the 
patient was sent back to his home in the country, quite well. 

In a case which I saw in consultation, the addition of brom- 
ism to other symptoms led to the diagnosis of cerebral lesion of 
the gravest kind, when really only the basal dura mater was in- 
volved. The following is a summary of this to me instructive 
example of the evils of the purposeless giving of the bromides 
in large doses. 

I was sent for to see Mrs. X. in a country town, near New York, on 
October 18th, 1875. She was under the care of a very intelligent practitioner, 
and had been seen by a prominent oculist of New York. I learned that this 
lady, then aged fifty-five years, had enjoyed goo.d. health during her adult 
life. In 1863, in Europe, she had an attack of mydriasis on the right side, 
without diplopia, or ptosis, or lesion of the fundus, or headache. This dis- 
appeared in three or four months. In 1870, having been well during the 
interval, while again in Europe, experienced internal strabismus of right eye 
with diplopia, but no pain. An oculist of Naples performed tenotomy of the 
internal rectus without relief. She had not then (and has never had) neu- 
ralgic pains in the legs, osteoscopic pains, sore eyes, or sore throat ; never 
was dizzy or faint. In 1872 had pain in the head for the first time, in the 
shape of neuralgia of the right supra-orbital nerve. This pain has been 
present ever since with great variation in intensity. Patient was often 
awakened by severe pain at 3 or 4 o'clock a.m. The pain soon affected the 
whole of the right temporo-frontal region, with some extension into the eye- 
ball and orbit. About one year ago (1874), and often since, had tingling in 
all the superficial branches of the right trigeminus. No irritation of the 
acoustic nerve. During the past year the sight of the right eye gradually 
failed, and slight exophthalmus appeared. Returned to America about one 
month ago, and was fairly well on board ship. Soon after landing, the local 
head and brow pains became much more severe, the pain apparently shooting 
through the right anterior lobe of the brain. There was no ptosis, but the 



232 ABUSE AND USE OF BROMIDES. 

• 
eyeball was fixed in internal strabismus, without dilatation of the pupil. Bro- 
mide of potassium was then given internally in doses of 4. and 6. per diem, 
blisters were applied behind the ears, and morphia exhibited. Patient became 
weaker. On Oct. 1st, ptosis appeared, there was only perception of light in 
the right eye ; vision normal in the left eye. The bromide of sodium was 
then substituted for the potassium salt, and given in doses ranging from 6. to 
12. per diem. Patient grew weaker and weaker, was stupid, used wrong 
words, staggered while standing or walking ; hands were tremulous. Oct. 
12, bromides stopped and the iodide of potassium given in .60 doses three 
times a day. About this time slight anaesthesia of the right brow was dis- 
covered. 

I found the patient, on the 18th, in a state of hebetude, speaking a little 
thickly and slowly, and quite often using the wrong word. She is perfectly 
intelligent. There is an abundant flow of buccal saliva and nasal mucus, 
but no acne. The left side of the face and the tongue are normal. Smells 
with both nostrils. On the right side there is ptosis, and on raising the eye- 
lid the eyeball is found immovable nearly in the median line, its pupil of 
medium size and fixed ; only perception of light on this side. The ophthal- 
moscope shows simple atrophy of the optic nerve ; there is no choking of the 
disk and no trace of hemorrhages in the retina. The fundus of the left eye 
is normal, and its vision is good ; field not impaired. The seat of pain is as 
described above. The brow, temple, and fronto-parietal region on the right 
side are partly anaesthetic. There is no palsy of the face or extremities, no 
anaesthesia of fingers, no referred sensations (numbness, etc.). The walk is 
titubating but not hemiplegia Patient repeats that she has never lost con- 
sciousness. Her pulse is regular, beating 80 in the minute, and her buccal 
temperature is 37° C. The attending physician and the consulting oculist 
had concurred in diagnosticating a tumor in the right middle fossa of the 
skull, involving the brain. 

My own conclusion was that we had to deal with an inflammatory affection 
of the dura mater in the right middle fossa of the skull, compressing the 
nerves, etc., which pass through the optic and anterior lacerated foramina, 
and not involving or affecting the brain substance. The cerebral symptoms 
present seemed to me to be those of bromism, partly by their intrinsic char- 
acters and mode of appearance, and partly because they were not those which 
a lesion at the base of the brain, on the right side, could produce. Further- 
more, I rejected the idea of a cerebral lesion because of the absence of hemi- 
opia and of lesion in each eye, of hemiplegia on the opposite side, both of 
which symptoms a tumor in the middle fossa must of necessity produce by 
pressure upon (a) the right optic tract and (p) the right crus cerebri. 

As to the nature of the inflammation, I gave no opinion ; the social posi- 
tion of the patient, her blooming family of children, and her own medical 
history previous to 1870, being opposed to a syphiltic theory. Still I con- 
sidered that we were in duty bound to give her the benefit of the doubt, and 
I urged the attending physician to continue withholding the bromides, to give 
the iodide of potassium in gradually increasing doses, to relieve the pain by 
hypodermic injections of morphia, and to support the patient with food and 
stimulants. It will suffice, for the present purpose, if I state that after 15. # of 



ABUSE AND USE OF BROMIDES. 233 

iodide of potassium per diem was reached and passed, improvement began 
and progressed rapidly. The medicine was carried up to 24. a day, and held 
at that dose for some time, then gradually decreased ; doses of .60 being 
taken as late as the spring of 1876. The symptoms of supposed cerebral 
lesion passed away in a few days, and the local symptoms gradually disap- 
peared, except the atrophy of the optic nerve. I met this lady a few months 
ago, and she seemed in perfect health, with the exception of slight imperfec- 
tions in the movements of the right eyelid and eye-ball, and of loss of vision 
in the eye. 

It would be easy for me to relate other cases, illustrating the 
proposition that bromism may embarrass diagnosis, but my 
space is limited, and the two examples given above are perhaps 
sufficiently demonstrated. 

I should add, however, that apart from the above special 
symptom-groups, the use or abuse of bromides may give rise to 
a condition of general debility, and to a weakness of the heart, 
which are not then by any means as serious as when not pro- 
duced by the bromides. 

III. Bromism in its medico-legal aspects. 

I am not aware that bromism has ever been brought into the 
courts as a matter for study and decision, but it may eventually 
be so under several circumstances. 

First, with respect to the responsibility of the physician ad- 
ministering the medicine which so debilitates a patient, physi- 
cally and mentally, as to expose him to various mishaps. For 
example, I know of a case in which the patient, suffering from 
acute bromism, fell asleep in a railway station, and was robbed 
of four hundred dollars, so great was the stupor produced by 
bromides, by thieves who undoubtedly wondered at the man's 
indifference to their manipulations. Dr. Hammond * relates, in 
his essay on Bromism, the case of a gentleman, one of his pa- 
tients, who was arrested on the street for drunkenness, and 
locked up over night in spite of the doctor's remonstrances and 
explanation. 

Second, as to the patient's responsibility for criminal acts 
committed while brominized. It is perfectly possible that such 
a patient shall take from a store articles not paid for, through 
defective memory ; that he shall be mistaken in the identity of 
persons, and thus be led to be improperly familiar or abusive ; 
or that he shall enter a house or room not his own, etc. 

* Journal of Psychological Med. , 1. c. 



234 ABUSE AND USE OF BROMIDES. 

Third, with respect to the legal capacity, both for ordinary 
business and for testamentary disposition, of brominized per- 
sons. Each case will, of course, have to be studied by itself, 
but it must be admitted that in some cases of bromism, the 
stupor, loss of memory, and aphasiform difficulty are so great 
that the patient is, for the time being, as truly no%i compos mentis 
as if he had a natural secondary dementia. 

A decision will be the more difficult to reach, because in mild 
and in moderately severe bromism the judgment and general 
intellection are remarkably well preserved, behind a veil of 
striking superficial symptoms, as impaired articulation, stupid 
expression, staggering gait, partial weakness of memory, muscu- 
lar weakness and tremor, etc. Again, in some cases, it will be 
necessary to make a close analysis of the patient's antecedents, 
in order to clearly ascertain how much of the mental impair- 
ment depends upon the medicine, and how much upon the dis- 
ease for which the medicine was prescribed or taken. 

Fourth, with reference to the production of death through 
bromism. This idea is suggested by reading a case of fatal 
bromism related by Clarke and Amory,* in which a nurse, lit- 
erally applying orders given him by a physician, continued 
giving enormous doses of bromide of potassium in spite of pro- 
gressive weakness. When seen by Dr. Clarke, the patient was 
past recovery, and sank in a week. 

There is a possibility that this procedure may some day be 
repeated with criminal intentions ; e.g., for the purpose of 
getting rid of a burdensome and incurable invalid. 

I shall now procee'd with the second part of this paper, viz., 
a statement of my own mode of using the bromides in the treat- 
ment of epilepsy and other neuroses. 

In prescribing the bromides for epilepsy, I have been guided 
by ideas which can, perhaps, be best expressed in the form 
of terse prepositions. 

1. In view of what we know of the physiological and toxic 
effects of the bromides, and in accordance with either of the 
two generally received hypotheses of their modus operandi, 
ansBmia and debility, or congenital feebleness, contra-indicate 
prolonged use of the bromides.- 



* The Physiological and Pathological Actions of the Bromide of Potassium, 
Boston, 1872, p. 62. 



ABUSE AND USE OF BROMIDES. 235 

2. The bromides are, on the contrary, well borne by persons 
of fairly full habit and good nervous power. 

3. The bromides are indicated in cases of abnormally great 
irritability of the nervous system, in its motor (muscular and 
vaso-motor) and ideational tracts. 

4. Epilepsy is so serious a disease, one which, if not inter- 
rupted, kills the patient, or reduces him to dementia, that we 
are justified in using unusual and heroic measures in its treat- 
ment. Hence, the contra-indications named above are to be 
much less regarded in the management of this formidable 
neurosis. 

5. As a corollary to the last proposition, I may state that 
I consider epilepsy to be the only disease for the cure of which 
we are justified in deliberately producing a degree of bromism. 

My method of prescribing the bromides in a common case 
of " idiopathic " epilepsy, is the following ; 

I employ one of two solutions,* made according to a stand- 
ard formula. 

3 Potassii bromidi — - 30. 
Ammon. bromidi - 15. 

Aqua? font. - 220. cc. 

M. 
S. To be given by the teaspoonful. 

K Sodii bromidi - - 30. 

Ammon. bromidi - 15. 

Aqua? font. - - - 220. " 
M. 
S. ■ To be given by the teaspoonful. 

These simple solutions, which I have found much more palat- 
able to most patients than those made with infusions or 
syrups, contain forty-nine doses ; i.e., each teaspoonful contains 
.60 of the potassium or sodium bromide, and .30 of the ammo- 
nium bromide. 

The solution is given several times a day, nearly always so 
divided as to give by far the largest dose in the evening. This 
is Brown-Sequard's rule, and the principle involved is to keep 
the system thoroughly under the influence of the drug during 
the night. 

* Latterly chloral hydrate has been very frequently substituted for the bromide 
of ammonium. — [R. W. A.] 



236 ABUSE AND USE OF BROMIDES 

I direct for an adult male epileptic, that a teaspoonful shall 
be taken before each meal, and two teaspoonfuls at bed-time, 
largely diluted. In the case of delicate males and of females, I 
at first prescribe only a teaspoonful before two meals, and two 
teaspoonfuls at bedtime, and in some young persons or very 
small and tender adults only, one dose before breakfast, and 
then at bedtime. The patient taking these initial or trial 
doses is carefully observed, the sensibility of the palate and 
throat frequently studied, and information obtained from the 
patient and his friends as to the absence or presence of stupor. 
Guided by these signs, or their absence, I cautiously increase 
the bromide, still keeping the nocturnal dose the largest, until 
slight bromism is produced, as evidenced by absence of reflex 
movements in the throat, and slight stupor. I pay but little 
attention to acne. During the rest of the treatment, I aim to 
give the patient just as little bromide as shall prevent attacks 
of epilepsy, yet I nearly always find it necessary to keep up 
slight bromism for months. 

The precise amount required per diem in a given case can 
only be determined by careful observation of that case, and is 
not to be deduced from general experience. At times, remark- 
able idiosyncrasies are observed which inexplicably render the 
patient very susceptible or very rebellious to the bromic influ- 
ence. Yery many of my patients take, month after month, one 
dose (1. of the two bromides) before each meal, and three doses 
(3. at bedtime) ; a total of 6. As extremes illustrating peculiari- 
ties, I may cite the case of a girl of twelve years, who for weeks 
took 9. per diem without bromism, and that of a young lady of 
twenty, who was decidedly influenced by one teaspoonful before 
breakfast and two at bedtime ; a total of only 3. per diem. In 
the latter case, had I given the usual doses taken by adults, I 
should have produced severe bromism. 

With respect to children I find that they tolerate the bro- 
mides (and iodides as well) in relatively large doses, and little 
patients of mine often take 4. of the bromides a day ; while to 
mere infants I give (after careful trial of smaller doses) 1.2 to 2.5 
a day. 

It appears to me very important to thoroughly dilute the 
bromides, in order to facilitate their absorption ; I usually direct 
that the dose be taken in a winesdassful or half a tumblerful of 
water. Furthermore, I give the medicine on an empty stomach. 



ABUSE AND USE OF BROMIDES. 237 

"With respect to the practice of giving a very large dose at 
bedtime. Theoretically, upon physiological grounds, it appears 
right to obtain the greatest bromic action in those hours when 
the reflex power of the motor part is probably heightened, and 
when epileptic seizures often occur ; and again, as a great num- 
ber of hours must elapse before another dose can be taken, it 
seems right to give an extra large amount to keep up the medic- 
inal effect. Empirically there can be no doubt of the great im- 
portance of this rule. Brown-Sequard's extraordinary success 
in the treatment of epilepsy was in part due to this, and I have 
several times seen patients who had been taking a large amount 
of the bromides in three equal doses without much improve- 
ment, who have had fewer attacks immediately after sub- 
dividing the same amount in such a way as to give a large dose 
at bedtime. For example, 2. three times a day did a little 
good, but 1. before each meal and 3. at bedtime checked the 
disease much more. 

Another of the reasons of Brown-Sequard's success was his 
positive direction that under no circumstances should the bro- 
mides be discontinued ; and I have always studiously followed 
his teachings in this matter. The bromides may be diminished 
but never stopped until the word cure can be pronounced. Even 
during intercurrent acute diseases, as colds, fevers, accidents, 
the bromides should be given regularly, though in reduced 
doses, partly because the nervous system resists less in that 
condition, and partly because such attacks of illness or accident 
interrupt the epileptic habit. The omission of the bromides for 
a very few days may allow a fit to occur, and thus destroy the 
good work done by months of patient care. 

How long must the bromides be taken in epilepsy ? This is 
a question to which we can as yet give no answer. Brown- 
Sequard and Yoisin give it for at least three years after the last 
attach, and I think that this is a minimum of time. I have twice 
been grievously disappointed by the return of attacks after an 
immunity of over two years, and others have known recurrence 
to take place after even a longer period. 

Some patients who have had epilepsy for many years are par- 
tially demented, and take the bromide unkindly ; they become 
irritable, feeble, and have nearly as many attacks as without the 
drug. In such cases parents will often ask you if it is worth 
while to give the bromides systematically, and to bear with the 



238 ABUSE AND USE OF BROMIDES. 

bromic symptoms. I generally answer this question negatively, 
yet state to the parents that as the patient may die in a par- 
oxysm it is our duty, on general principles, to do anything which 
shall diminish that risk. 

It will be inferred from the foregoing that I rely upon the 
bromides of ammonium, sodium, and potassium for the treat- 
ment of epilepsy, and this is in one sense so. 

No medicine, it is now generally admitted, has such power 
over the epileptic habit, and does good in so many cases, as the 
bromides, and it would seem as if the day for trifling with such 
doubtfully efficacious medicines as zinc oxide and sulphate, 
copper sulphate, belladonna, strychnia, setons, diet, etc., had 
passed away. With the bromides of calcium, lithium, zinc, and 
arsenic, I have had little or no experience. The last named is 
loudly vaunted by Clemens, of Frankfort on the Ehine. 

I would not, however, have it understood that I employ only 
the bromides in the treatment of epilepsy. On the contrary, 
what measure of success I have is owing in part to the fact that 
I made a large use of other means, together with the bromides ; 
and this seems to me so important that I shall take the liberty 
of digressing a little to specify what this adjunct treatment is. 

In the first place, I employ means which tend to counteract 
the unpleasant effects of the bromides.. 

The acne may to a certain extent be prevented by adminis- 
tering arsenic from time to time, either in the shape of the 
solution of arsenite of potassa, or of' arsenious acid. Sulphur 
ointments, mercurial plaster, alkaline lotions, may also be em- 
ployed. 

The general debility or slight paresis produced by the " con- 
tinuous dose " (Clarke) of bromides is corrected by strychnia, by 
nux vomica and zinc oxide, and by quinia. Drowsiness and the 
more serious symptoms of bromism are relieved by inhalation 
of nitrite of amyl, by stimulants, and by quinia. The anaemia 
and general depression of the vital functions produced in the 
course of the management of a case of epilepsy, I meet by care 
in giving the patient nutritious diet, by giving cream or cod- 
liver oil, and by administering such medicines as iron, quinia, 
phosphorus, strychnia, with nitro-muriatic acid, wine, beer, or 
whisky, and by regulating the patient's hygiene. 

Important hygienic rules in the treatment of epilepsy are 
the avoiding of large meals at night, regulating the functions of 



ABUSE AND USE OF BROMIDES. 239 

the bowels, kidneys, and skin, early rising, and great moderation 
in sexnal gratification. 

In the second place, I employ, in some cases, a few medicines 
which act more directly upon the morbid state of the nervous 
centres. These are belladonna, cannabis indica, oxide* of zinc, 
strychnia, sulphates of zinc and copper, etc. My favorite is the 
first named, and I have known the best effects to follow its asso- 
ciation with the bromides. For example, a patient passed into 
my hands after having been a long time under the treatment of 
a distinguished physician with a moderately good result ; under 
a given quantity of the bromides she had attacks about fort- 
nightly. I did not increase the bromides or change the method 
of taking them, but at once gave extract of belladonna in closes 
of .02 three times a day. The patient acquired a dryness of the 
throat, and the attacks were reduced in frequency to once a 
month, once in two months, three months, and she has now 
been thirteen months without an attack. Of course the bella- 
donna was not continued during all the two years of treatment. 
At first it was used for two or three months in succession, and 
afterward given from time to time. 

During the many months or years of the treatment of a case 
of common epilepsy, I ring the changes on the medicines above 
enumerated, nearly always giving something in addition to the 
bromides. And I may be allowed to repeat that the bromides, 
though often changed in amount, and sometimes in kind, are 
never withheld. 

The treatment of cases of epilepsy in which a definite causa- 
tive lesion can be made out, is, of course, somewhat different. 
I refer now to epilepsy due to syphilitic lesions, to peripheral 
disease, to cranial and neural injury, etc. In these varieties I 
use the bromides to combat the epileptic habit, to prevent dis- 
charges (using Hughling Jackson's phraseology), and at the 
same time meet the special indication by using mercury and 
iodide of potassium, by correcting visceral disease, by removing 
some external irritating cause, or by an operation like trephin- 
ing, neurectomy, etc. 

In other neuroses, I have used the bromides sparingly, and 
never continuously. 

Hystero-epilepsy and hysteria have not seemed to me much 
benefited by the bromides. As far back as 1857, Laycock re- 
marked that the bromide of potassium was especially successful 



240 ABUSE AND USE OF BROMIDES. 

in hysteria of distinctly ovarian or uterine origin. I would not 
condemn the use of the bromides in hysteria, but would protest 
against their being given in such a manner as to produce bromism. 

Insomnia, I think, is often treated by bromides, upon the 
purely hypothetical indication of causing anaemia of the brain — 
an indication reposing upon insufficient physiological experi- 
mentation, and upon belief in the notion that the bromides di- 
rectly produce cerebral anaemia. Many cases so viewed might 
be much more quickly relieved by chloral, or by a glass of ale, 
or by correcting indigestion. A case of well-marked insomnia 
needs, it seems to me, to be investigated in the broadest man- 
ner, without failing to keep in mind that this symptom may 
depend upon a number of pathological conditions. As to the 
immediate cause of sleep, I believe it to be due partly to the 
waste of tissues generally, and the presence in the blood of an 
accumulation of the products of retrograde metamorphosis 
(Preyer's theory), and partly to the exhaustion of the cerebral 
tissue itself. The anaemia which is observed in the brain dur- 
ing sleep is, it appears to me, a concomitant, or consequent phe- 
nomenon, in obedience to the general law that a tissue in repose 
contains less blood than one in action. 

Insanity is often, I believe, erroneously treated with the 
bromides. I have several times seen patients with melancholia 
made weak and wretched by large doses of the bromides which 
failed to make them sleep ; and in mania I have known precious 
time wasted in vain attempts to get sleep by these medicines. 
I would only employ the bromides in insanity to meet a few 
indications, such as a tendency to epileptiform attacks, or ab- 
normal sexual excitement, or great nervousness not caused by 
delusions. 

I have not used the bromides in chorea and neuralgia. It 
is vaunted in migraine, but in some half dozen cases in my 
practice it has given absolutely no relief to the attack. Extreme 
irritability of the bladder with pain, in a female, was very greatly 
relieved by a retained vaginal injection of 2. bromide of ammo- 
nium. The idea was to produce anaesthesia of the vagina and 
vulva. Upon a similar principle we all use gargles of bromides 
in neuralgic or myalgic sore-throats, and in the cough of laryn- 
geal irritation, with fair success. Yomiting in pregnancy, after 
morphia, ether, etc., may be arrested by judicious use of the 
bromides. It has been proposed to give bromide of potassium 



ABUSE AND USE OF BROMIDES. 241 

an hour or so before administering ether, or giving opium or 
morphia, with the view of preventing nausea and vomiting. 
This practice has seemed successful in my hands also. 

Hay-asthma, or hay-cold, is a disease for which multitudes 
of medicines have been tried, without much good result. Last 
year, I induced two or three persons suffering from this disease 
to employ a strong gargle of bromide of ammonium, and to wash 
out the nasal passages with a weak solution of the same salt 
several times a day during the attack. The result was so grati- 
fying that I am disposed to ask physicians to give a fair trial 
to this treatment during the coming summer and autumn. The 
gargle to be of the strength of 4 or 8. of bromide to 30. cc. 
water ; the solution for the nares, much weaker, of from .60-2. 
of bromide in 30. cc. water.* 

* New York Medical Record, Nov. 11, 1876, p. 737. 
16 



A CONTBIBUTION TO THE THEEAPEUTICS OF MI- 

GBAINE* 

Gentlemen : — The contribution to the therapeutics of migraine 
which I have the honor to read this evening, will probably strike 
you as very fragmentary and inconclusive, but I would ask you 
to consider in a charitable spirit that it is the result of only a 
few hours' work, and that it is intended as a suggestive rather 
than a didactic and formal essay. 

So short has been the time which has elapsed since I was 
asked to participate in this evening's work, that I have not been 
able to collect scattered notes of cases and to make inquiry of 
former patients ; both of which would have been necessary had 
I wished to base my statements upon statistics. At some future 
time it may be possible to supply the data upon which the suc- 
ceeding assertions rest. 

Briefly stated, my thesis is that by the long-continued use 

OF CANNABIS INDICA, MIGKAINE OR SICK-HEADACHE MAY BE CUBED, MUCH 
BELIEVED, OB MITIGATED IN SEVEBITY. 

This idea is not by any means original with me, but was 
brought out by an English physician, Dr. Bichard Greene, who 
published a short article upon the subject in The Practitioner, 
vol. ix., p. 267, London, 1872. After reading the article I imme- 
diately began using the remedy, cannabis indica, as directed by 
Dr. Greene, and have continued to do so ever since. My former 
partner, Prof. William H. Draper, has also used the treatment 
somewhat during the same period of time ; and both of us have 
been much gratified by the results obtained. I may add that 
some inquiry has convinced me that, in this country at least, 
the article passed unnoticed, and the plan has not been generally 
tried. 

Before proceeding to give details concerning the treatment, it 
might not be amiss to recapitulate the diagnostic characters of 
migraine or sick-headache. This affection is essentially neural- 

* Read before the Section on Practice of Medicine in the New York Academy 
of Medicine, Nov. 20, 1877. Reprinted from the N. Y. Medical Record, Dec. 8, 

1877. 



THERAPEUTICS OF MIGRAINE. 243 

gic in its chief manifestations, viz., a severe or excruciating pain 
in the head and orbit, but not along the superficial branches of 
the trigeminus. It affects both sexes, from the age of six or ten 
years to that of forty or fifty. In some patients it makes its 
first appearance at puberty and terminates before the sixtieth 
year. In females it may, after undergoing aggravation or trans- 
formation, cease at the menopause. Very rarely does the dis- 
ease cease before thirty, and still more rarely does it first appear 
at that age. 

Migraine is pre-eminently an inherited disease, perhaps more 
directly so than any other neurosis. I possess numerous tables 
of families in which many members of three generations were 
affected. 

Migraine is periodic in its manifestations, nearly as much so 
as epilepsy ; patients have attacks every two months, or monthly, 
or every week — seldom several in a week. In some women the 
periodic return of migraine coincides with menstruation. 

An attack of sick-headache usually begins in the very early 
morning and lasts all day — seldom longer in uncomplicated cases. 
In many cases certain premonitory symptoms precede the oc- 
currence of pain. The day or evening before the attack some 
feel unusually bright and well. At the earliest waking on 
the day of attack there may be chilliness or numbness of a lim- 
ited part of the body, dim vision, colored vision, or hemiopia. 
These optical disorders are of exceeding interest, and are best 
observed in those patients whose attacks begin some time after 
rising. They usually last less than half an hour. Although 
amblyopia, hemiopia, photopsia are often very serious symptoms, 
yet in migraine they lose their prognostic significance. In other 
persons nausea is an early symptom. Pain follows upon the 
above disturbances and sometimes makes its appearance without 
them. It is usually in one side of the head, hemicrania ; deeply 
placed "in the brain" or "back of the eye," as patients tell us ; 
it grows in intensity, is sharp, or beating, or pressing, and may 
reach such a degree of severity that patients strike their heads 
violently against hard objects, use chloroform, or beg for hypo- 
dermic injections of morphia to obtain relief. During the exist- 
ence of this pain, which may extend to the rest of the head, 
there is hyperesthesia of the eye and ear, great irritability, pal- 
lor of the face, cool skin, intense nausea, and severe vomiting. 
So prominent a symptom is vomiting, so early does it appear, 



244 THERAPEUTICS OF MIGRAINE, 

and so abundant is the matter ejected, that the sufferers gener- 
ally, and, I regret to say, physicians occasionally, consider the 
headache as caused by "biliousness," thus reversing the true 
order of cause and effect. For a while after vomiting there may 
be some relief to the suffering. 

Toward evening the pain diminishes in intensity, changes its 
character to a dull general headache, and after a night's sleep 
the patient awakes quite well ; in many cases feeling better than 
before the attack. Sometimes, however, in gouty subjects, or in 
women at the menopause, headache more or less typical will 
endure for two or three days. 

It should be added that there are cases in which no nausea 
or vomiting appears ; and patients are disposed to separate 
these from the category of sick-headache, and speak of them as 
" nervous headaches." I believe that these two varieties are of 
the same general kind — of the migraine type. 

It would be out of place in this short paper to trace out the 
varieties and transformations of migraine, and I have only said 
enough of the symptomatology to make it unmistakably clear 
what are the cases in which the plan of treatment about to be 
presented is applicable. 

The pathology of migraine is one of the most open questions 
in medicine, and I can only briefly state my own opinion, reached 
by a careful study of physiological considerations and clinical 
data. I believe with Anstie and many others, that a lesion (at 
present undemonstrable) exists or occurs in those parts of the 
pons and medulla oblongata which give origin to the sensory 
roots of the trigeminus. Yarious systemic states, and various 
irritations from the external world,* the abdominal organs, the 
cerebrum, serve to provoke the attacks. 

One very potent exciting cause of attacks is mental overwork 
or anxiety ; another generally recognized is that condition of the 
system in which oxalate of lime appears abundantly and 
frequently in the urine, and in which uric acid quickly separates 
from it — in brief, acidity, or a gouty disposition. Indigestion 
may also be an exciting cause. 

Guided by the above pathological and serological notions, I 
have treated migraine by — 

* Of late Dr. Seguin was inclined to ascribe some migraines, especially bastard 
or non-typical attacks, to an optic or visual origin — to eye-strain. — [R. W. A.] 



THERAPEUTICS OF MIGRAINE. 245 

1. Treating the patient, and removing all exciting causes. 

2. Treating the attacks themselves. 

3. Treating the disease, or the supposed fundamental patholo- 
gical state in the nervous system. 

First. — The treatment of the patient consists in removing all 
relievable exciting causes, and more especially in correcting 
acidity. For this purpose I employ the ordinary means, viz., 
giving nitro-muriatic acid and alkalies, and greatly reducing the 
saccharine and amylaceous foods of the patient.* In cases 
attended by debility, anaemia, and imperfect nutrition, it may be 
necessary to resort to tonics, including cod-liver oil. 

Second. — Treatment of the attack. The first thing to be done, 
in my opinion, is to place the patient under circumstances which 
secure quiet and semi-darkness. The attempt to " fight out " a 
sick- headache is nearly always vain, and may be injurious. It is 
better net to allow the patient any food, not even liquids, until 
toward the close of the attack, or even not till next day ; by this, 
nothing is lost, and much wretchedness is avoided. Ice, or ice 
washed in brandy, is grateful. 

If the patient have a warning (aura of migraine) before nausea 
or pain, much can, I believe, be done to cut short the attack or 
diminish its severity by the use of guarana, caffeine, or croton 
chloral hydrate. In my hands, guarana or the powder of the 
seeds of paullinia sorbilis, has proved very efficacious. I have 
prescribed the fluid extract of guarana, Caswell & Hazard's Elixir 
of Paullinia, the French Paullinia powders, and powdered 
guarana prepared by our druggists, and all of these preparations 
have in my hands often cut short or prevented attacks, if given 
in the early stage of the disorder. 

Of the elixir or fluid extract I give a teaspoonful, to be 
repeated twice, at an interval of an hour. The powders are 
administered in 1.2-2. doses, also repeated every half hour or 
hour. I think that I may report that nearly one-half of my 
patients have derived great relief from some preparation of 
guarana, and that in several of them attacks have been absolutely 
prevented, and they have been enabled to go about on the 
same day. 

Caffeine, in doses of .12, repeated every hour, until three or 

* Since writing this paper Dr. Seguin's belief in the lithaemic element in 
many cases of migraine, has been very much strengthened by the great success 
often attending this plan of treatment.— [R. W. A.] 



246 THEBAPEUTICS OF MIGRAINE. 

four doses have been taken, I have lately employed, upon the 
recommendation of my friend Dr. Geo. M. Beard, and# it has 
appeared to do good. 

Croton chloral hydrate, recently recommended in all neu- 
ralgic affections of the head and face, I have recently prescribed 
in doses of 1.-1.2 repeated every hour until four doses are taken 
or relief obtained. This remedy is to be used more especially 
in cases where pain is the first symptom, and in other cases if 
seen when the pain is fully established. 

I have no personal experience with the use of large doses of 
bromide of potassium and of alcoholic stimulants, for the relief 
of attacks. 

Hypodermic injections of morphia, .02-.03, and atropia, .001, 
have permanently relieved attacks in a few of my cases ; but I 
am very reluctan^ to employ this means, so fraught with the 
danger of the formation of the opium habit. I never allow my 
patients to take opium or morphia themselves in this disease. 

I would add that there is very probably a real ultimate use- 
fulness in shortening or preventing every attack which may 
threaten to occur during the systematic treatment of the neu- 
rosis. We may thus be doing a good deal to interrupt the morbid 
habit which the nervous centres have acquired. 

Third. — Treatment of the disease. No treatment of this sort 
had been tried, to my knowledge, before Dr. Greene made his 
remarkable researches upon the effect of .cannabis indica. Dr. 
Greene reported cases of many years' standing as having been 
months and years without attacks while and after taking canna- 
bis indica, and in other extremely bad cases marked reduction 
in the frequency and severity of the attacks was obtained. 

I have said, in the opening page of this small contribution, 
that I and a few medical friends have used the cannabis treat- 
ment ever since Dr. Greene's publication, and with satisfactory 
results. 

The principle of the treatment is to keep the nervous system 
steadily under a slight influence of cannabis for a long period of 
time; in other words, we are to employ the " continued dose " 
of the remedy, as Clarke and Amory say in speaking of the use 
of bromide of potassium in epilepsy. 

I give to adult females .02 of the alcoholic extract of cannabis 
indica before each meal, increasing the dose after a few weeks 
to .03. Males can generally begin with .03, and it is well to give 



THERAPEUTICS OF MIGRAINE. 247 

them .045 in two or three weeks. These doses must be taken 
with the greatest regularity, just as faithfully and regularly as 
bromides in epilepsy. Indeed, when beginning such treatment, 
I usually obtain a promise from the patient that he will regu- 
larly take the pills for a period of three months. 

As a rule, no appreciable immediate effect is produced by the 
above doses, though I have known lightness of the head and 
slight confusion of mind to result from an initial dose of .03 
three times a day. 

Under this apparently and essentially simple plan of treat- 
ment, I have known what may be termed excellent results to be 
obtained. Of course, I do not mean to say that all my patients 
have been benefited, but, without a statistical table, so difficult 
to construct from the experience of private practice, I feel cer- 
tain that about one-half of my cases have been relieved. A 
few — two or three — after being more than a year without return 
of their migraine, have passed from under immediate observa- 
tion. One of these now very rarely has headache, although for 
several years he has taken no medicine. The majority of patients 
relieved have obtained months of freedom from attacks while 
taking the remedy. 

I think that we may say of cannabis for migraine that it is 
nearly as efficacious as the bromides in epilepsy. Both may 
cure, both do bring about remarkable interruptions in the series 
of attacks, both must be employed in the shape of the continued 
dose. 

Cannabis in migraine is less effectual than the bromides in 
epilepsy, but, on the other hand, it is superior to them in not 
producing unpleasant or injurious effects. 

My friends and former partners, Drs. William H. Draper and 
Frank P. Kinnicutt, have used the above plan of treatment fre- 
quently in the last five years, and their results substantially 
agree with my own. 

Some surprise naturally arises upon seeing so much good 
done by small doses of a neurotic medicine in a disease so 
deeply rooted as migraine. Our wonder may never cease 
respecting the modus agendi of the drug — its essential potent 
action ; but its gross and practically interesting effect is very 
analogous to a well-established acquisition of empirical thera- 
peutics. I refer to the successful employment of belladonna 
or atropia in epilepsy. This treatment, especially vaunted by 



248 THERAPEUTICS OF MIGRAINE. 

Trousseau, is by no means useless, although it is no longer fash- 
ionable since the more useful bromide treatment has come into 
general use. I still, however, employ belladonna in epilepsy in 
conjunction with the bromides, and this combination sometimes 
brings about gratifying results. 

I may be allowed to briefly mention one illustrative case. 
"When Dr. Brown-Sequard went to Europe in 1875 one of his 
patients came under my care. She had a bad form of epilepsy, 
and in spite of the most skillful use of the bromides by her illus- 
trious physician she had been having a fit every two weeks for 
months. I made little change in the amount of bromides she 
was taking, merely substituting my own simpler solution for 
Brown-Sequard' s mixture, and gave her .015 of belladonna three 
times a day — just enough to keep her throat a little dry. From 
the very beginning of treatment the epileptic attacks became 
fewer ; intervals of one, three, and fourteen months being ob- 
tained. In the present year, owing to the uncontrollable cause 
of the epilepsy, she has had three or four seizures. 

A close parallel may, I think, be drawn between the two dis- 
eases, epilepsy and migraine ; and between the two remedies, 
belladonna and cannabis ; thus, in my opinion, logically fortify- 
ing the propositions advanced upon empirical grounds, that can- 
nabis is useful in the treatment of migraine. 

1. Migraine and epilepsy are both nervous affections charac- 
terized by the occurrence of periodical attacks ; the attacks 
themselves in both diseases are largely made up of vaso-motor 
disturbances ; in both it is probable that the medulla oblongata 
is primarily or secondarily diseased ; both affections occur in 
the same families, and may be present at successive times in the 
same patient. The late Dr. Anstie has expressed the opinion 
that the two diseases are akin, and states* that migraine may 
develope into genuine epilepsy. I have in my private case-books 
cases illustrating this proposition, and I am now treating a phy- 
sician who states that after nocturnal epilepsy appeared, before 
beginning bromide treatment, his old migraine grew less frequent 
and less severe. 

2. As regards the two remedies, cannabis and belladonna : 
both are intoxicants and deliriants ; both dilate the pupil, and 
it is probable that the action of both upon the central nervous 

* The Practitioner, vol ix. r 1872, p. 356 



BULBAR PARALYSIS. 249 

system, when administered in the shape of the continued dose, 
is very similar. 

In conclusion, I would earnestly ask the gentlemen who have 
honored me with their attention this evening, to give the canna- 
bis treatment of true migraine a critical trial. 



BULBAK PARALYSIS (AN ATYPICAL CASE OF LABIO- 
GLOSSO-PHAEYNGEAL PARALYSIS).- 

Male, aged 67. Patient of Dr. McCready, seen in consultation 
Sept. 25th, 1876. He was a steady drinker. Probably no 
syphilis. At least a year ago great difficulty in swallowing 
began, especially of liquids, and it steadily increased. In the 
winter of 1875-6, Dr. McCready was suddenly called and found 
patient in extreme and dangerous orthopncea, without cardiac 
or pulmonary cause. The respiration was of the Cheyne-Stokes 
type, a few rapid acts of breathing, succeeded by a long pause, 
with shallow and short inspirations. Ever since, breathing has 
been more or less of this type. Children have noticed stagger- 
ing gait and stooping in the last few months, and in the same 
period a degree of imperfection in articulation has shown itself. 
On Sept. 19th, partial right hemiplegia without loss of conscious- 
ness. Dr. McCready saw patient shortly afterward, and made 
sure that although the power of articulation was nearly abol- 
ished, there was no aphasia. After this attack the breathing 
became much more difficult, and deglutition has been nearly 
abolished ; almost nothing being swallowed until to-night. Food 
has been administered per rectum. I found the patient in a 
state of semi-stupor, from which he could be roused. The 
pupils were normal ; expression dull ; lower part of face expres- 
sionless. Mouth hangs half open and its right corner and cheek 
drop. The breathing is shallow and rapid for a few seconds, 
then almost imperceptible (Cheyne-Stokes type). The grasp of 
both hands is weak, that of the right hand weaker. In attempt- 
ing to talk patient makes great effort, but the sounds are almost 
inarticulate and guttural. He names daughters, days of the week, 
etc., and seems not to be at all aphasia Labial sounds are best 

* Journal of Nervous and Mental Diseases, vol. v., Jan., 1878, p. 134. Abstract 
of a paper read before the New York Neurological Society, Dec, 1877. 



250 TUMOR OF OPTIC THALAMUS. 

made, cannot distend cheeks with, air or whistle, but purses lips 
fairly well. Tongue is only partly projected ; it shows neither 
atrophy nor tremor. An autopsy showed uniform atrophy of 
cerebrum, sub-arachnoid effusion, etat crible in extreme degree. 
No other lesion appreciable to naked eye. 

Under the microscope, lesions of the medulla oblongata 
usually present in this disease were found. 



LOCALIZED BASAL MENINGITIS IN CHILDKEN * 

Gentlemen : — I desire this afternoon to call your attention to 
a class of cases in which the use of the ophthalmoscope is strik- 
ingly advantageous, and this in the hands of those not expert in 
the handling of the instrument. 

Case I. — This little girl, aged six years, was brought to my class at the 
Manhattan Hospital a couple of weeks ago, with the following simple history : 
For two or three weeks she had complained of headache, had vomited fre- 
quently, and on February 9 (a week ago) internal strabismus appeared. The 
patient has not complained of impairment of vision, she has not had fever, 
spasm, or delirium. Constipation has, however, been marked. She is 
anaemic looking, a small brother of hers probably has phthisis, and one child 
of the same parents is said to have died of "brain fever." My assistant at 
the Manhattan Hospital, Dr. Adam, immediately examined the child's eyes 
with the ophthalmoscope, and found double neuro-retinitis, a diagnosis which 
I concurred in, and which was verified by Dr. Webster in the Ophthalmic 
Department of the Hospital. Consequently, the most important symptom 
was the one revealed to us by the use of the ophthalmoscope. I made the 
diagnosis of basal meningitis localized about the chiasm of the optic nerves, 
probably without tubercular deposit. Tiie child was blistered behind the 
ears, and given .60 of potassium iodide three times a day, with instruction to 
increase the dose by .30 per dose, every second day. 

As you see the child now she does not seem sick, and were it not for the 
convergent squint, you would probably consider her as only a delicate, 
anaemic child. In the last few days the headache and vomiting have ceased, 
and improvement has begun. 

I shall now relate two analogous cases from my private practice. 

Case II. — Referred for examination to Prof. H. Knapp, on May 2, 1877, a 
girl, aged four years, previously healthy. First symptoms noticed about five 
weeks before examination, consisting chiefly in dullness, irritability, slight 
headache, and, on one occasion only, vomiting. Two weeks later internal 
strabismus (one eye) suddenly set in, and has persisted. No fever, spasm, or 
delirium. Previous to this attack there had been no emaciation, or cough, 
or ill-health of any kind. Dr. Knapp found double neuro-retinitis, with 
paresis of external rectus of one eye. On examination, I found the child with 
the above optic symptoms, and very cross; the buccal temperature was 37.2° 
C, and the pulse 96, perfectly regular. I made the diagnosis of non-tuber- 

* A Clinical Lecture delivered at the College of Physicians and Surgeons, New 
York, Saturday, February 23, 1878. From the Hospital Gazette, Mar. 1, 1878. 



252 LOCALIZED BASAL MENINGITIS IN CHILDREN 

cular localized basal meningitis, and expressed the opinion that the child's 
life was in no danger, though vision might remain considerably impaired. 
Dr. Knapp was giving potassium iodide, which I also advised. A few days 
ago Dr. Knapp informed me that a few weeks after I saw the child the stra- 
bismus disappeared, and that the neuro -retinitis gradually gave place to 
atrophy of the optic nerves, which, fortunately, was but slight, so that vision 
is now nearly perfect. 

Case III. — Sent me for examination by Prof. C. R. Agnew on February 14, 
1878. I learned that the patient, a little girl five years old, had gone through 
an attack of chicken pox early in January, without fever or apparent ill- 
health. About January 19th the left eye "turned in," and strabismus has 
been constantly present since. No other symptoms have been observed — no 
fever, headache, irritability, etc. The mother states that one of her former 
children, at the age of eleven months, had convulsions and fever, became 
unconscious, and died in two weeks. 

Examination of the eyes by Dr. Agnew reveals " double optic neuritis, with 
some stuffing of the disks; hypermetropia 4.5 of each disk." 

I made the same diagnosis as in the second (first in point of time) case, viz. : 
local basal meningitis of non-tubercular nature. Advised blisters behind the 
ears, and large doses of potassium iodide. 

These three cases illustrate a form of disease which is not, to 
my knowledge, treated of in the text-books, yet one which I sus- 
pect is not very rare, and which the more general use of the 
ophthalmoscope would render yet more common. Without a 
view of the fundus of the eyes in these little patients their trouble 
would have seemed strange or trivial. For, consider how few 
symptoms they presented. 

Headache was present in two of them, and was frequent or 
severe only in one. 

Vomiting occurred frequently in one child, ouly once in Case 
II. , and not at all in Case III 

Irritability and change in disposition (a real symptom in chil- 
dren, under many circumstances) occurred in only one child. 

Strabismus occurred in all, and was, in reality, the only symp- 
tom which alarmed the parents, and caused them to seek advice. 
In Case II. Dr. Knapp expressly states that he found paresis of 
one external rectus, but in Case I. the muscles seem fairly 
strong, and it has occurred to me that perhaps, in these cases, 
the squint is due to a stronger accommodative effort which the 
child unconsciously makes to obtain better vision, as in the 
squint which accompanies hypermetropia. In Case III. there 
was hypermetropia of 45. 

Neuro-retinitis was present in all the cases. Such important 



LOCALIZED BASAL MENINGITIS IN CHILDREN. 253 

symptoms of intra-cranial disease as convulsions, delirium, paraly- 
sis, fever, irregularity of the pupils, and of the pulse-rate were ab- 
sent in all the cases. In none of the cases was the basal disease 
secondary to any serious general fever or constitutional state. 

The condition of the optic nerves and retina found in these 
cases is known as neuro-retinitis, or choked disks. In this state 
the optic nerves appear swollen, and may project considerably 
(measurably) above the level of the surrounding retina ; the mar- 
gin of the disk is obscured or wholly lost, and no line of demar- 
kation can be made out between the nerve and the retina. The 
blood-vessels present striking anomalies, the arteries being rel- 
atively small, the veins positively large and tortuous ; there are 
often small hemorrhages in the retina, round about the disk. 
This condition of choked disk may last a number of weeks (much 
longer in cases of tumor of the brain) and then subside, giving 
place to the appearances of atrophy of the optic nerves, viz.: an 
unnatural whiteness, or bluish whiteness of the disk, smalmess 
of the retinal vessels, and unusual sharpness of the outline of 
the disk. A degree of atrophy must be looked upon as inevit- 
able in the stage of recovery in cases such as those related above ; 
hence we must be cautious in prognosis as regards vision. 

I would next invite your attention to the probable seat of 
lesion in these cases, and the mechanism by which choked disk 
is set up. At the base of the brain, anterior to the pons Yarolii, 
and between the two temporal lobes, is a vast reservoir of sub- 
arachnoid fluid, contained in the meshes of the pia mater, in the 
so-called anterior subarachnoid space. Within this space lie 
the chiasm of the optic nerves, the roots of the olfactory bulbs, 
and the trunks of the third, fourth, and sixth nerves, on their 
way to the orbit. Each of these nerves, but more especially the 
optic, has a lymphatic circulation of its own, within its sheath, 
and in communication with the sub-arachnoid space. In reality, 
the same fluid which fills up the anterior sub-arachnoid space 
circulates in the lymphatic spaces of the optic nerves as far as 
the eyeball. When inflammation occurs at the base of the brain, 
or when a tumor is placed there, there is, of necessity, produced 
a retardation in the two circulations of the optic nerves— their 
blood circulation and their lymph circulation — and in conse- 
quence blood and lymph accumulate in the head (or retinal end) 
of the nerves, the arteries are small, the veins enlarged, and some 
of these may burst. Thus may all the optic phenomena of basal 



254 LOCALIZED BASAL MENINGITIS IN CHILDREN 

meningitis be explained. But, besides more active processes, 
exudation, and migration of leucocytes may take place in the 
delicate optic structures, and result in serious mischief. The 
effects upon the motor nerves are readily explicable by the same 
mechanical causation; but it is a little difficult to understand 
why the sixth nerve, which is certainly more robust than the 
fourth, should alone suffer. That is, upon the supposition that 
paralysis is actually present, and that we have not to deal with 
an accommodative squint. 

We ought, with such a lesion so placed, to have some impair- 
ment in the function of smell. This is an interesting point which 
has not yet been investigated, I believe. 

I have spoken of meningitis and tumor as giving rise to choked 
disks, and it may be well for me to say why I do not believe that 
tumors are present in these cases. First — Tumors of the basis 
are rare in children ; they generally have intra-cerebral or cere- 
bellar tumors of the tubercular kind. Second — A basal tumor 
will give rise to more positive paralytic symptoms than are pres- 
ent in our cases ; either decided palsy of one or more cranial 
nerves, or weakness of the limbs on one side. Third — Convul- 
sions would form a prominent feature in the symptom-group. 

While regarding the lesion as an inflammation of the pia mater, 
I do not believe that it is tubercular, because of the absence of 
aggressiveness on the part of the disease, the absence of previous 
sickness, or of focus whence tuberculization might be set up; 
and, lastly, because in one case, recovery easily and rapidly oc- 
curred. 

As to treatment, I would advise iodide of potassium in doses 
varying from .60-4. three times a day, well diluted. These little 
ones bear the iodide wonderfully well, when it is gradually in- 
creased. Counter-irritation has some effect at first, and I would 
place blisters behind the ears or on the temples — quite a 
series. At the same time I would give the child light but nutri- 
tious diet, keep it quiet, and avoid everything which produces 
determination of blood to the head, as active play, anger, sur- 
prises, etc. There is no need, I think, of confining the patient 
to the house. 

Finally, gentlemen, I am pleased to speak to you of these 
cases, in order to give you faith in the value of the ophthalmo- 
scope in the hands of the non-expert. I do not ask you to believe 
in the diagnosis, by any but our best oculists, of delicate lesions, 



A BRAINLESS FCETUS. 255 

such as slight ansemia or hyperemia of the fundus of the eye, or 
faint atrophy of the optic nerves ; but you, and all practitioners, 
should be able to recognize a fairly normal optic disk and retina, 
and to distinguish such gross lesions as choked disks, hemorrhage 
of the retina, and marked atrophy of the optic nerves. I trust 
that before you enter upon the practice of your profession, after 
finishing the elementary curriculum of the winter, you will seek 
private instruction in the use of the ophthalmoscope, and thus 
arm yourself with a weapon which will enable you to do more 
good, to improve your reputation by correct diagnoses, and, 
what is often more advantageous, to avoid damaging that reputa- 
tion by an unfounded favorable prognosis in cases such as these, 
in which all signs, except the hidden ones, are not serious. 



A CLINICAL AND THEBAPEUTICAL CONTKIBUTION 
TO OUR KNOWLEDGE OF CERVICAL PARAPLE- 
GIA.* 

I pbesent the following histories of cases to illustrate the 
senieiology of cervical paraplegia, and to demonstrate that the 
disease, in some of its forms, may be checked or even cured. 

Case I. Atrophic paralysis and anaesthesia in both hands ; 
symptoms of weakness and stiffness in the legs ; removal of these 
symptoms, and permanent arrest of the disease. 

Dr. R , U. S. Army, aged 41 years, first consulted me in 1873, and re- 
lated the following history: Had always enjoyed good general health, never 
had syphilis, or been injured about head and spine, but had been much ex- 
posed to hardship and overwork in his army service. In December, 1870, he 
suddenly experienced diplopia with internal strabismus due to palsy of the 
left sixth nerve. This was not preceded or accompanied by neuralgia or by 
general symptoms. This affection gradually disappeared in the course of two 
months. 

In July, 1871, the present disease made its appearance. Dr. R. was then 
in camp, and had been much exposed in severe marches. On rising one 
morning he noticed a marked degree of palsy in his left hand, the abduction 
of the thumb being impossible and opposition almost lost. At the same time 
both hands felt stiff and numb, though whether this was from palsy or from 
cold he could not decide. Dressing was very difficult that morning. The 
result of this attack was marked palsy of parts of the left hand and slight 
impairments of the motor functions in the right. The doctor cannot state 
positively what was the condition of sensibility in the right- hand at that 
time. Three months later neuralgic pains appeared in the left thumb and 
forearm, and at the same time the thenar eminence on the left side began to 
waste rapidly. About the same time a diffused (corset-like) sense of constric- 
tion was noticed round about the chest, extending from beneath the clavicles 
to the lower ribs. At that time there was no palsy or wasting of the right 
hand ; no symptoms in the face. The gait was unsteady, and fatigue easily 
produced. Closing eyes and attempting to walk in darkness made this un- 
steadiness greater. Late in the autumn of 1871 numbness (anaesthesia?) was 
first positively noticed in the ulnar distribution of the right hand, and this 
has since increased. At that time there was no numbness on the left side. 
This hand first became numb in the summer of 1872, one year after the palsy. 

* From the Journal of Nervous and Mental Disease, July, 1S78, vol. v. 



CERVICAL PARAPLEGIA. 257 

During the past six months the atrophy of the left hand has increased, as 
well as the anaesthesia. During this period the right thenar eminence lias 
shown a beginning of atrophy about its centre (flexor brevis pollicis) ; the 
abductor indicis and the dorsal interossei also show some wasting. The 
fingers have been very awkward in use ; the medius and annulus seeming to 
stick together. There has been much increase in the anaesthesia of the right 
hand. jSTo general symptoms have appeared except moderate emaciation. 

Examination.— -The patient is a tall spare man of good muscular develop- 
ment, and no sign of disease except his wasted hands. Nothing abnormal 
about eyes, internally or externally. Facial muscles act well. On the left 
side there is a considerable area of partial anaesthesia in the range of distribu- 
tion of the superficial branches of the supra-orbital, infra-orbital, and malar 
branches of the fifth nerve. Contact is hardly felt in this region, but painful 
impressions are perceived. The upper part of the trunk is the seat of much 
numbness, and some anaesthesia (r). At times it seems to patient as if a 
cuirass were round about him, extending as low down as the false ribs and 
the umbilicus. No such sensation lower down. 

Both hands are the seat of muscular atrophy and anaesthesia distributed as 
follows : The left hand is extremely wasted. The small muscles of the thumb 
have disappeared, with the exception of the inner part of the flexor brevis and 
adductor. Complete extension and opposition of the thumb are impossible. 
The muscles of the hypothenar eminence and the interossei are uniformly 
wasted. The atrophied muscles yield no contraction to the strongest faradic 
current, and only slight fibrillary contractions to the interrupted current of 
thirty-two elements of Stohrer's galvanic battery. 

The right hand exhibits a very moderate wasting of the interossei, and a 
narrow streak (6 mm.) of positive atrophy in the abductor and opponens 
pollicis. The interossei controlling the index and medius fingers are most 
affected. The various muscles of the hand, excepting the atrophied band in 
the thenar group, respond well to both currents. The handwriting is much 
altered and laborious, the patient feeling as if the difficulty were one of inco- 
ordination, though this is not strictly correct. On neither side is there the 
main-en-griffe which is so characteristic of extreme palsy of the interossei. 
The forearms and the rest of the body are free from paralysis or atrophy. 

Sensibility is much impaired in both hands, but more in the right ; so that 
we see in this case an imperfect example of the phenomena accompanyiug a 
lesion in one half of the cord. The degree of tactile anaesthesia is great, but 
pain and temperature are everywhere perceived when the stimulus is suffi- 
ciently strong. In the right upper extremity the loss of sensibility is in the 
inner (ulnar) side of the lower arm, forearm and two-thirds of the hand, the 
whole of the fingers and part of the thumb anteriorly. The left upper ex- 
tremity exhibits a patch of anaesthesia a little different in shape. Anteriorly, 
the inner (ulnar) half of the lower arm and of the forearm is slightly anaes- 
thetic, and the same is true of the same parts of the posterior aspect of the 
forearm and hand. In the hand the anaesthesia almost follows the distribu- 
tion of the ulnar nerve. 

There is a faint feeling of numbness in the remainder of the upper extrem- 
ities as high as the acromion processes, but there is no true anaesthesia. 
15 



258 CERVICAL PARAPLEGIA. 

In the lower extremities there is nothing objectively abnormal. At times 
there is marked uncertainty in walking, patient feeling in danger of stagger- 
ing against persons and things. There is no ataxia, and while standing with 
eyes closed no great oscillation. The doctor was formerly a great walker, 
but now he is easily fatigued by half a mile of promenade. No rectal or 
vesical symptoms. 

Diagnosis. — I reject progressive muscular atrophy, because 
of (1) the paralytic onset; (2) the occurrence of anaesthesia; 
(3) the limitation of disease to the hands ; (4) the want of sym- 
metry in the wasting. There was probably a small hemorrhage 
in the spinal cord at the time of sudden paralysis of the left 
hand. If there was a clot it must have been very small, and 
was located in the left anterior gray horn in the middle of the 
cervical enlargement. From this focus a myelitis has extended 
in a direction chiefly downward and across the median line. 
The most remarkable feature of the case is the grouping of 
symptoms in the order assigned by Brown-Sequard to spinal 
hemiplegia, i.e., more palsy on one side (same side as lesion of 
spinal cord), and more anaesthesia on the opposite side. 

During the autumn and early winter of 1873 I treated Dr. R. systemati- 
cally. The local treatment, having for its object the improvement of the 
atrophied muscles, consisted in thorough galvanization of the parts, friction, 
etc. A few fibres of the left thenar eminence seemed to revive and grow 
after weeks of patient care, but no real progress was made. 

It was otherwise with the internal treatment. Under the use of nitrate of 
silver, arsenic, cod liver oil, etc., the myelitis was undoubtedly arrested. Be- 
fore leaving for the Pacific coast early in 1874 Dr. R. could walk much, felt 
less inclination to stagger, was much less conscious of the cuirass feeling, 
and gained a great deal in general vigor. 

Dec. 1, 1875. In the last eighteen months no medicines have been taken, 
yet the disease has made no progress. The hands are about the same, lie has 
hardly any sense of constriction about the thorax, he walks perfectly well, 
and his health is good. 

Looking over the history and progress of the case in the 
light of recent discoveries in the pathology of spinal paralysis, I 
am disposed to modify my first diagnosis somewhat. I adhere to 
my denial that the case was one of progressive muscular atrophy, 
but doubt if at any time there was hemorrhage in the cord. 
The original lesion may have been a rapidly developed limited 
myelitis in the left anterior gray horn in the lower cervical 
region, with subsequent chronic myelitis in various directions, 



CERVICAL PARAPLEGIA. 259 

chiefly across the median line, backward and downward. The 
case bears a certain resemblance to cases of acute spinal paraly- 
sis in the adult. The weight of evidence is very nearly equally 
in favor of both my hypotheses. 

1877. I have several times met Dr. E. in the last two years, 
and he has always expressed himself as perfectly well except in 
his hands, which remain as they were in 1873. All signs of 
active myelitis have long since disappeared, and we may assume 
that the disease has definitely come to a stand-still. 

Case II. — Atrophic paralysis in both hands with slight 
anaesthesia ; neuralgic pains in both arms ; weakness of legs. 
Treatment by active counter-irritation, mercury and iodide of 
potassium, galvanism ; cure. 

Mrs. H., aged 53 years, was brought to me by my friend Dr. Conrad, of 
this city, on July 30, 1877. I obtained the following history : Some time 
during January of the present year she began to experience pain and numbish 
sensations in the tips of the index and medius fingers, later in thumb and 
palm of hand. There were no abnormal seusations in the ring and little 
fingers. The left hand alone was at first affected. She thinks that previous 
to January she had had some pains in arms, but cannot describe them. 
These pains (those occurring in late winter) were followed by weakness and 
wasting of the hands. 

In May, when seen by Dr. Conrad, there was the following condition : 
The right hand was only a little weak ; the left was the seat of neuralgia and 
numbness as above described, the left thenar muscles were atrophied, and 
there was marked loss of power. Since that time the pains have been more 
clearly neuralgic, following the course of the median and ulnar nerves from 
the palms to the bends of the elbows, occurring in paroxysms every ten or 
thirty minutes, very seldom affecting both arms at the same time. There 
seemed to be more pain on the right side. About the middle of June numb- 
ness showed itself in the tips of the medius, index, thumb and palm of right 
hand. No numbness in range of radial and ulnar nerves. Closing hands has 
made the pain worse ; feeling in fingers and palms is a sore, scalded sensation. 
Has had some pain in the middle of the back below the shoulder ; no spinal 
pain strictly speaking ; no cerebral symptoms ; no numbness in feet, but 
legs have ~bee)i iceak ; no spinal epilepsy or cincture feeling. Complains of 
slight dysphagia. 

Dr. Conrad has given the patient small doses of biniodide of mercury and 
iodide of potassium, and had applied an ascending stabile galvanic current 
from the hands to the back of the neck. 

Examination. — Slight but distinct tactile anaesthesia in fingers supplied by 
median nerves (including inner half of annulus) ; for example on the tip of 
the medius finger the points of the oesthesiometer are distinguished only at 
4-5 mm. apart. There is marked paresis of both forearms and hands. Left 
hand tremulous. The only atrophy visible is in the outer part of the left 



260 CERVICAL PARAPLEGIA. 

thenar eminence. The other muscles are weak but not visibly wasted. A 
faradic current applied to the median and ulnar nerves (nerve current) pro- 
duces contractions in all muscles except the part of the left thenar eminence 
which is wasted. The median nerves are not tender or unduly irritable under 
pressure in any part of their course. 

The patient has had several miscarriages and other symptoms which justify 
a suspicion of syphilis. Has been taking 2. of iodide of potassium a day, and 
galvanism. 

I made the diagnosis of central myelitis in the upper part of the cervical 
enlargement, chiefly in the left half of the organ, involving the anterior gray 
horn. My advice was to insure absolute rest for the hands and arms, patient 
not even to feed or dress herself ; to apply mercury by inunction, and to 
give the iodide of potassium in much larger doses. The actual platinum 
cautery was shortly applied over the upper cervical vertebrae. 

August 11. Again seen with Dr. Conrad. Patient is no worse as regards 
pain and atrophy. The legs are perhaps weaker. Mercurial ointment to the 
amount of 40. has been used without effect on the gums ; has had 9. of iodide 
a day. Advise repetition of cautery every other day, the use of 12. iodide per 
diem, more inunction, also 4.cc. of Squibb's fluid extract of ergot at bed-time. 
Mrs. H. has been rather careless in respect to resting hands. She is strongly 
urged to do nothing whatever with them. Very mild galvanism to arms and 
spine. 

Sept. 11. Patient is better in some respects. There is no increase of wast- 
ing, less pain and dysesthesia in Angers. Legs arc weak, but without 
increased reflex. In the night the hands become clenched. A little tremor 
is observed in the lips. Treatment has been faithfully pursued ; counter- 
irritation, rest, biniodide of mercury and iodide of potassium in large doses ; 
ergot up to 8. at night. The gums have been kept a little tender. During 
the winter iodide of potassium internally, and galvanism to the hands and 
spine in the shape of the ascending stabile current, constituted the treatment. 
Almost absolute rest was enforced. Improvement appeared and continued. 

March 9. Seen with Dr. Conrad. Patient is practically cured. The mus- 
cular masses of the hands are fully restored ; grasp is good. Very little neu- 
ralgic pain is now felt in the arms, but lately some pain has appeared in elbows 
and knuckles. There is a mere trace of numbish feeling in the fingers. Legs 
only feel weak after going up stairs. Continues iodide and galvanism. 

A few weeks ago, in May, I met Dr. Conrad, and he informed me that with 
the exception of occasional neural pains, his patient was perfectly well. 

In concluding this case I would express my thanks to Dr. Conrad for his 
courtesy in allowing me to make use of it, and would congratulate him upon 
the skill with which he carried out the treatment agreed upon. 

Case III. — Extreme anaesthesia of both upper extremities and 
of the upper part of the trunk ; atrophic paralysis of the right 
hand and of many muscular groups of the left upper extremity; 
contraction of the left pupil. No symptoms in the lower limbs 
except rigidity in the left leg. Central myelitis in the cervical 



CERVICAL PARAPLEGIA. 261 

enlargement of the spinal cord, with probable formation of a 
cavity. 

Annie M , single, aged 23 years. Seen at the Manhattan Hospital, May 

18, 1878. When twelve years of age patient's ankles were weak for two years, 
hut entirely recovered. Five years ago, when eighteen years old, she noticed 
numbness in the tips of the fingers of both hands, extending to the shoulders 
in the course of a few months. The legs were not numb. Next there began 
wasting of the left shoulder, hand and arm. Since at least two years the left 
arm has hung useless, by her side. The right hand has wasted more recently. 
Has felt fibrillary contractions from the start, and believes that sensibility 
was early lost in the hands. The left leg is weak, and in the last three 
•months it has been getting very stiff. At night her whole body jerks. 
Micturition is only slow ; constipation is present ; menses are regular. No 
dyspnoea, or palpitation. Has some occipital headache. According to pa- 
tient's statement, feeling in the feet and legs is normal, though at times the 
left foot tingles. Has never had neuralgic pains in arms or legs. General 
health good. 

Examination. — Both pupils are small and equal in a bright light ; in the 
shade the left does not expand, while the right does. jSTo paralysis, atrophy, 
or anaesthesia in the face. Face not flushed. The upper part of the thorax 
and the shoulders present marked anaesthesia and analgesia ; in the upper 
part of the back and shoulders behind, sensibility to touch and pricking is 
fair. In the arms, forearms and hands sensibility is wholly lost ; patient has 
often burned herself without knowing it. The left upper extremity is exten- 
sively paralyzed, while the right is only partially so in the hand. State of 
muscles : On the right side only the interossei are weak and Avasted. On the 
left side the following muscles are atrophied and palsied : interossei, biceps, 
brachialis anticus, supinator longus, supra and infra spinati, and deltoid. 
The flexors and extensors of fingers and wrists, the triceps and pectoralis are 
simply feeble. The scapula? are not winged ; there is a slight dorsal spinal 
curvature, convexity to the right ; no kyphosis ; standing with eyes closed is 
difficult ; left lower extremity is the seat of increased reflex and epileptoid 
trepidation. jSTo atrophy or paralysis of lower limbs. Measurements : right 
calf, 32 c. ; left, 31 c. Tendon (knee) reflex increased on both sides. 

Re-examined in bed, May 19, 1878. The face presents only. the symptoms 
above noted. The upper extremities, as high as the insertion of both deltoids, 
are perfectly anaesthetic to touch, reasonable j3ricking ano l pinching, and to 
firm grasp. On the upper thorax and back on the shoulders, she feels touch 
fairly well, but pricking very little. In front, normal sensibility reappears at 
the level of the fourth rib. On the back the limiting line is indistinct and 
seems to be somewhat below the spines of the scapulae. Motor symptoms in 
arms as above. The lower limbs and the abdomen present no anaesthesia. 
Legs and thighs are well nourished ; left calf very firm; left toes are "en 
griffe " ; foot not inverted. Patient's mother states that her left leg is very 
stiff in bed and on first rising in the morning, but after walking it becomes 
more limber. Patient denies having a cincture feeling or dyspnoea. When 
numbness appears in the left leg (rarely) it extends to the knee, but patient 



262 CERVICAL PARAPLEGIA. 

qualifies the statement by saying that the feeling is more like cramp. At the 
age of twelve years it would seem that patient had an attack of palsy in the 
left leg below the knee ; the leg and foot were swung heavily for awhile. At 
that time the left arm was not affected. She recovered perfectly in two years. 
Every symptom now observable in the left leg and foot has appeared within, 
the past year. The temperature of the hands, taken for three minutes with 
a Casella thermometer, placed between the index and medius, is, on the right 
side 34.7° C, on the left 35.° C. 

Electrical examination, June 3d. Faradic current, right upper extremity. 
All muscles give good reaction except the outer group of dorsal interossei. 
Left upper extremity, good reaction in trapezius, pectorals, triceps ; proper 
extensors of wrist and fingers ; faint reaction in long flexors of wrist and 
fingers, inner third of deltoid, opponens pollicis ; no reaction in hyjiothenar 
group, inner part of thenar group, interossei, supinator longus, and biceps. 

It is plain that in this case there is a great lesion in the cer- 
vical enlargement of the spinal cord ; probably a diffused cen- 
tral .myelitis with formation of a cavity. The lesion was first 
developed in the sesthesodic tract of the cord, and is yet greater 
there than in the kinesodic system, though the anterior horns, 
especially on the left side, have become involved. The cilio- 
spinal centre in the left side of the cord is injured, as shown by 
the contracted pupil. It is noteworthy that no symptoms of 
vasomotor paralysis are present, thus affording a demonstration 
of the independence of the cilio-spinal and facial vasomotor 
centres. The symptoms in the left lower extremity point to the 
existence of secondary descending degeneration in the lateral 
column. 

It is very remarkable that with so much disease in the cer- 
vical enlargement, the various nervous conductors for the lower 
limbs and abdomen should not be interfered with. As regards 
the uppermost limit of the lesion, that cannot be above the 
origin of the fifth cervical nerve, as the diaphragm acts per- 
fectly. 

A few words as regards the pathology of these cases. 

In all three the sesthesodic, kinesodic, and musculo-trophic 
tracts in the cervical enlargement were affected. 

In Cases II. and III. the affection was probably inflammatory 
— perhaps syphilitic in Case II. In Case I. a doubt may exist as 
to whether hemorrhage took place, or whether there was a 
suddenly developed (as in infantile poliomyelitis anterior) in- 
flammatory lesion. Even if there was hemorrhage at first, a 
secondary adjacent inflammation occurred and presented many 



CERVICAL PARAPLEGIA. 263 

of the symptoms. I am disposed to believe that a central cavity 
has formed in the cervical region in Case III., because of the 
resemblance of this case with the cases of central myelitis with 
formation of cavities reported by Schueppel, Hallopeau, and 
others. 

As regards therapeutics, the exceedingly satisfactory issue in 
Case II. was perhaps obtained because the lesion was essentially 
syphilitic, and the proper remedies were freely and persistently 
used. Yet I am disposed to attribute much of the recovery to 
the almost absolute rest enforced. On careful consideration, in 
view of the apparently progressive nature of the lesion, the issue 
in Case I. is almost as gratifying. True, the atrophied and 
anaesthetic hands were not restored, but symptoms which seemed 
to point to approaching general paralysis were permanently dis- 
pelled. Case III. has been but a few days under treatment, and 
is a very unfavorable one. 



A CONTKIBUTION TO THE PATHOLOGICAL ANAT- 
OMY OF DISSEMINATED CEKEBKO-SPINAL SCLE- 
KOSIS.* 

Me. President and Gentlemen : — This thesis is based upon 
two cases. Case I. came under the observation of Dr. Yan Der- 
veer, of Albany ; the history is as follows : 

Thos. Grogan, accountant, aet. 29, unmarried. Mother died at the age of 
49, during her climacteric period, from the exhaustion following sciatica. One 
brother died of phthisis pulmonalis at the age of 26. Several brothers and 
sisters died during infancy. The father, a brother and a sister are still living, 
and in good health. Saw the case first in Feb. 1870, when the following 
facts were elicited : 

Habits have always been good ; no sexual excess or masturbation , and has 
not been exposed to venereal diseases. Has been quite studious and had 
acquired a good education. Was fond of society, and spent many of his 
evenings at dances up to the time he was taken sick. 

In the latter part of December, 1867, his attention was first attracted to a 
sharp pain about an inch back of the right eye. He was impressed with the 
idea that he had strained the eye and began wearing a pair of spectacles. 
While attempting to haug a picture, he noticed that he could not see it dis- 
tinctly enough to determine whether it was hung properly or not. In April, 
1868, had frequent nocturnal emissions, but did not apply for treatment. 
While attending a military funeral in June, of this year, with a prominent 
organization of this city, he experienced no trouble in his power of loco- 
motion until he had walked about five blocks, when he began to stagger like 
a drunken man, and after several ineffectual attempts to march steadily, was 
obliged to leave the ranks. He immediately returned home, and consulted 
his family physician, avIio thought that lie was probably suffering from a 
partial sun-stroke. Xo particular treatment was ordered aside from rest, and 
partially recovering his strength he returned again to his office duties. In 
August he was much annoyed by a feeling of internal warmth in the lower 
part of the left leg, but adopted no treatment. Went to Pennsylvania in 
October to secure rest and recruit his health. Any unusual excitement at 
this time would cause severe nervous tremors and a sensation " akin to creep- 
ing of the flesh." During his visit he suffered much pain in the left ankle 

* By Dr. E. C. Seguin, New York, in collaboration with Dr. J. C. Shaw, 
Brooklyn, and Dr. A. Van Derveer, Albany. (Reprinted from Journal of Ner- 
vous and Mental Disease, April, 1878.) 



DISSEMINATED CEREBROSPINAL SCLEROSIS. 265 

and thought he had sprained it, but could not tell when or how he had 
done so. 

He returned to his home about November 1st, and applied himself closely to 
business until the middle of February, 1869, when his strength failing he 
gave up business by the advice of his physician. Was confined to the house 
during three weeks, regarding his weakness as due to overwork. During the 
winter of 1868-69, Dr. Alden March applied the moxa several times to his 
spine. At the close of his three weeks' confinement he was again able to 
take exercise in the open air, and walked with the aid of a cane. In the 
course of four or five weeks lie was again much prostrated, so much so that he 
himself entertained serious apprehensions concerning his recovery. He was 
now troubled with more or less flatulence, dizziness, loss of sight and con- 
stipation. Improved somewhat in May, and continued so until August. 
Went to Sharon Springs and took sulphur baths up to 37.75° Cent, daily 
during four weeks, and drank at the same time from one to two quarts of 
sulphur water eacli day. This produced great prostration, and he was brought 
home in four weeks greatly debilitated, and much reduced in strength and 
flesh, and now for the first time in the history of his case was he unable to 
walk without support. He first came under my observation in February, 
1870, when he presented the following more prominent symptoms: Strength 
somewhat improved since his return from the springs, and he can now, with 
great effort, walk alone, but gravitates in an irregular way from side to side 
while doing so. Complains of great weakness in his arms and legs, and a 
feeling of great constriction about the body. Cannot see to read, but can 
distinguish a friend at a distance across the street. His feet are very sensitive 
to tickling. Standing witli his feet together, when his eyes are closed, he 
thinks he would fall if left alone. Will not trust himself to come down 
stairs without watching his feet closely, and feels a sensation as if walking 
upon cushions. Drags his feet when walking. Can converse with little or 
no effort. Enjoys conversation, is humorous, and fond of quoting from 
Shakespeare. Is unable to whistle on account of a spasmodic twitching of the 
muscles on the right side of the face when he attempts it. Can put out 
liis tongue in all directions. Very difficult for him to attempt to rn'onounce 
the words, "truly moral." Generally sleeps well the latter part of the night, 
bowels constipated; pulse and respiration normal. Urine is passed without 
trouble, and at regular intervals in usual quantity; is acid, has a specific 
gravity of 1020 ; is heavily loaded with phosphates. Has seminal emissions 
from four to six times a month. Surface of skin is very hypersesthesie. Upon 
strong percussion along the spinal tract, feels some pain. Ordered 1.2 cc. 
fluid extract ergot three times daily, with good, generous diet, also directed 
him to take an occasional saline cathartic. Continued this treatment for 
three months and he thought he was improving, but, in fact, had not so good 
use of his limbs as before. 

June 1. Can whistle somewhat more distinctly, but complains that he is 
losing control of his arms. Feeds himself with difficulty. When asked to 
touch his nose with either index finger, his hand describes a semicircle, and 
as he approximates the finger to the nose, it is done with a sudden jerk. 

Ordered a pill, consisting of .002 strychnia, .015 capsicum, .06 reduced 



266 DISSEMINATED CEREBROSPINAL SCLEROSIS. 

iron and, as lie does not sleep, 1. bromide of potassium, to be taken at bed- 
time. Has frequent erections and great sexual desire. Urine still abun- 
dantly phosphatic in character. Continued the above treatment until Sept. 1st, 
with no amelioration, and a gradual loss of power of co-ordinating the lower 
limbs. Unable to walk alone, and walks with difficulty when supported ; 
drags his legs along, advancing the heel first with a jerk. Ordered phosphor, 
acid and strychnia, with bromide of potassium at night. 

Dr. Clymer saw him about October 1st, 1871, and observed the following more 
marked symptoms in his disease : Tone of voice drawling ; brain seems 
weakened, and nystagmus of the eyeballs is apparent. Has, in addition, 
spinal epilepsy ; it having only a general connection with the sclerosis. The 
latter condition only occasionally present. Sensation in both limbs impaired. 
The muscular will-power in the right limb is good, but much weakened in 
the left, and in the latter, sensation is confused and tardy. Sensation of 
heat or cold, or the impression of a sharp instrument, reaches the brain much 
sooner from the one part than another. There is characteristic dragging of 
the feet, and the will-power is inadequate to give the proper stimulus to the 
muscles, yet he displays considerable control of the leg when attempting to 
extend or flex it. Took most of the time until October, 1872, a pill consisting of 
.0012 phosphorus, .002 strychnia, .06 reduced iron, but with no apparent 
benefit. October 1, 1872, Dr. Clymer saw him a second time. The spinal epi- 
lepsy still continues, but is not so marked. The muscular will-power is much 
weakened. Has lost much in flesh, and at times there have been well marked 
symptoms of paralysis of the right side of the face. Cannot whistle and 
talks very indistinctly at times. Urine phosphatic in character and bowels 
much constipated. No nocturnal emissions ; no sexual desire. Anaesthesia 
is very decided and sensation confused. Little treatment resorted to from 
this time until his death, except to keep his bowels regulated, and occasion- 
ally quinine to improve his appetite. Has to be fed, as he cannot carry 
anything to his mouth, having little if any control of his hands. Sight mucli 
impaired. Three months before his death his urine was withdrawn several 
times, and then again a week previous to his death. It became very difficult 
for him to talk three months before his death, but at no time were well marked 
symptoms of aphasia observed. His trouble in speaking seemed to be due to 
paralysis of the muscles. In Sept. 1871, Dr. Stevens examined his eyes with 
the ophthalmoscope and diagnosticated sclerosis of the optic nerve. 

Patient died Feb. 21st, 1874. At the autopsy — no general post-mortem 
being allowed — only the brain and spinal cord were examined, which were 
removed entire and sent to Dr. Seguin immediately. * 

Case II. came under Dr. Seguin's observation. 

Female, a?t. 23. Single. Seen Oct. 20, 1873. A nervous girl, with occa- 
sional irregularity of menstruation, but no dysmenorrhoea. At times hysterical 
laughter and tears ; never convulsive attack. In July, 1871, while out walk- 
ing, after having climbed a number of walls, felt weak and awkward in right 

There is not enough evidence to 

History by Dr. Van Derveer. 



DISSEMINATED CEREBROSPINAL SCLEROSIS. 267 

support this statement. Ever since she has had weak right leg, without an- 
aesthesia or numbness ; at times more use of leg than at others ; almost cured 
once or twice ; of late has required help of crutch, or friend's arm in walking. 
When I examined Miss P., I found paresis of right leg, the loss of power 
being marked at ankle and toes. There was doubtful weakness of the right 
hand. I could not make out that the knee joint was affected. The muscles 
of the right leg showed a slight diminution of reaction to the faradic current, 
and this agent also showed that sensibility to pain was a little dull in leg and 
foot. 

In view of the history of the case, the capricious development of the palsy, 
the absence of reliable signs of central disease, the presence of a strong neu- 
rotic element in the family, and the fact that strong emotions had been 
acting upon her, I concluded that the patient had a functional palsy of an 
hysterical nature. Strychnia was given her and faradism used. The specific 
effects of strychnia appeared and the patient was decidedly tetanizcd for a 
while ; this passed off, and whenl last saw the patient, on December 11th, she 
was in about the same state as at the beginning of treatment . The unfavor- 
able effects of the treatment led me then to believe that the patient had an 
obscure central lesion, probably sclerosis. In March or April, 1874, patient 
rapidly grew worse, becoming paraplegic, and her hands showing paresis. In 
July she was placed in an irregular water-cure house, where extensive bed- 
sores formed in consequence of want of care and of cold applications to the 
palsied parts. (She had continuous applications for several days.) Exhaust- 
ion and pyemia caused death, August 1st. The post-mortem examination 
showed disseminated sclerosis of the spinal cord. The brain not examined. 
Dr. Charles A. Leale, of this city, treated the patient during July, after the 
bed sores had formed, and I made the autopsy at his request and that of 
Deputy Coroner Dr. Shine. 

After hardening in bichromate of potash, sections were made 
in various regions of the encephalon and cord in Case I. In 
the br-ain proper, small patches or nodules of sclerosis 1 to 3 
mm. in diameter exist in various parts of the white substance 
of the hemispheres ; and there are a few just under the gray 
cortex. In the right nucleus caudatus, near the posterior 
margin, are several nodules ; in the right occipital lobe just out- 
side of the posterior horn of the lateral ventricle, extending well 
back towards the convolutions at the apex of the lobe, is a long 
sclerosed patch. 

Pons and Medulla. — The upper part of the pons Varolii and 
crura have not been critically examined. In the medulla ob- 
longata the sclerosis appears in the following parts : 

1. At the level of the apex of the fourth ventricle (Fig. 5), and 
below, a patch about 2 mm. exists in the very centre of the 
section across the median raphe. 



268 DISSEMINATED CEREBROSPINAL SCLEROSIS. 

2. In a section made at a point 6 mm. above the apex of the 
fourth ventricle (Fig. 6), a large patch of sclerosis invades the 
floor of the ventricle, including the mass of gray matter which 
gives origin to the hypoglossus, par vaguni, and glossopharyn- 
geal. 

Few cells of the hypoglossus nucleus are visible, and these are 
small and rounded. 

3. In a section made through the point of origin of the 6th 
and 7th nerves at about 2 mm. above the inferior border of the 
pons Yarolii, the sclerosis is found in about the same location, 
viz. : round about the nucleus of origin of these nerves under the 
floor of the fourth ventricle (Fig. 7). 

Cord. — Sections have been made in the cervical, dorsal and 
lumbar regions, stained in carmine and hematosin, and mounted 
in Canada balsam. With a low power or with the naked eye the 
following distribution of the lesion can be made out : 

In the cervical region (Fig. 1), the sclerosis involves the fol- 
lowing districts : almost all the right anterior column, and the 
entire anterior horn, the posterior part of the left anterior 
column, and the whole of the anterior horn, the posterior part 
of the lateral column, a narrow band of cortical sclerosis of both 
posterior columns, the lower part of the columns of Tiirck near 
the commissure ; all the gray commissure involved in the dis- 
ease. 

In a section a little below this in the cervical region (Fig. 2) 
the location of the lesion is somewhat different. The most de- 
cided disease is confined to the anterior part of the left anterior 
column, a small part of the external edge of the anterior horn, 
the posterior part of the lateral column, the columns of Goll and 
the gray commissure. 

In the dorsal region (Fig. 3), decided sclerosis of outer part 
of left anterior column and the whole of the anterior horn, the 
columns of Tiirck, and a slighter sclerosis of all the cord poste- 
rior to a line drawn through the central canal. 

In the lumbar region (Fig. 4), the right anterior column and 
border of the anterior horn, the posterior part of the right lateral 
column, both posterior columns, gray commissure, and slight 
sclerosis of the periphery of left anterior horn. 

In Case II., only the spinal cord was obtained. 

In the cervical region (Fig. 8), the following districts are dis- 
eased : the columns of Tiirck, posterior part of right anterior 



Fig' 



FcMf. 



fig \% t 






Fid.5. 




FirtG. 




Kg. 7. 




Fig.3 




Fio-.X 







Jd13i 




270 DISSEMINATED CEREBROSPINAL SCLEROSIS. 

column, the upper part of right column of Burdach, the columns 
of Groll, posterior part of left anterior column. 

Sections just below above in the cervical region (Fig. 9) show 
the following distribution : the columns of Tiirck, part of right 
anterior and lateral column, the entire posterior columns, the 
periphery of the right anterior horn. 

Dorsal region (Fig. 10), columns of Tiirck, the periphery of 
both anterior horns ; the gray commissure, both lateral columns 
and both posterior columns. 

In the lumbar region (Fig. 11), the columns of Tiirck, right 
lateral column, posterior part of left anterior column, entire pos- 
terior column, the periphery of both anterior horns. It will be 
seen from this description that the sclerosed nodules are of vari- 
ous sizes, and occupy the most diverse regions of the cerebro- 
spinal system, involving the gray as well as the white matter. 

Histology. — The histologic study will include the two cases. 

For convenience of study and description we will divide the 
morbid process into three (3) stages. This division, although 
arbitrary, can nevertheless be observed, on a close study of the 
specimens, and aids very much in a description and the under- 
standing of the various conditions which are observed in the 
many diseased regions of the cerebro-spinal substance : " 

The first stage will comprise the very earliest changes which 
are to be observed. 

The second stage, in which the morbid process has advanced 
considerably. 

The third stage, in which the most extensive changes are to 
be seen. 

The Neuroglia. — First stage. An examination of the neuroglia 
of the white matter at this stage shows an increase in the size 
of the nuclei ; their number is also slightly increased ; there is 
an increase of the protoplasm around the nuclei, the quantity 
varying very much in different cells ; in most of the cells it is 
only a little greater than normal, in. a few it is enormously in- 
creased, as can be seen in Fig. 12, representing two cells seen in 
the anterior columns of the dorsal region in Case I. The nuclei 
have not only undergone increase in their size, but they have 
also assumed the most diverse shapes ; in those cells where the 
protoplasm is very much increased, the nucleus is found at the 

* The medulla and pons were examined by Dr. Seguin, the two cords and brain 
by Dr. Shaw. 



DISSEMINATED CEREBROSPINAL SCLEROSIS. 271 

extreme edge, as if the protoplasm had increased all on one side ; 
we also begin to notice slight processes from the protoplasm ; 
even now there is an appearance of increase in the size of the 
fasciculi of tissue running between the various areas of nerve 
tubes. At this time all the surrounding nerve tubes appear to 
be normal, their axis cylinders and myelinic sheath are perfectly 
distinct. In the gray matter at this period, the alterations are 
very similar : a slight increase in the size of the nuclei and the 
protoplasm around them, and beginning to be visible processes 
from the protoplasm. 

In the second stage, the nuclei and their surrounding proto- 
plasm have increased in size, their processes are now much 
larger, and more distinct and apparently more numerous ; and 
there is altogether a much larger number of these branching 
cells visible. There is now present a diffuse granular appear- 
ance ; no special fibrillation to be seen ; a very close observa- 
tion shows that the axis cylinders are present, but that their 
myeline sheaths have gone. (The granular appearance at this 
period is very probably due to. the breaking up of the myelinic 
sheath into a granular-looking material which becomes diffused 
among the surrounding tissue, and this perhaps also explains 
why we do not see the increased fibrillation of the neuroglia.) 
The process at this period is the same throughout the brain and 
cord ; in the gray as well as in the white matter. 

In the third stage these branched cells have grown to an 
enormous size, their processes are numerous and sometimes of 
immense thickness and length (Fig. 13) ; now very little granu- 
lar material is present, and we see distinctly the enormous in- 
crease of neuroglia fibres, and which are of exceeding coarseness ; 
there appears to be no evidence of anastomosis between them. 
In a stage a little advanced of this (Fig. 14), these branched 
cells appear much less numerous, they are less distinct, their 
nuclei are less sharply stained, their outlines are not so perfect, 
and they sometimes appear as imperfect bodies ; they in their 
turn appear to have lived their day, and are now undergoing 
decay. 

Nerve Fibres. — In the second of the artificial periods which we 
have created for convenience, we see the first changes in the 
nerve fibres ; their myeline sheath is undergoing disorganization ; 
but their axis cylinders still remain. 

In the third period, when the increase of neuroglia fibres is 



272 DISSEMINATED CEREBROSPINAL SCLEROSIS. 

at its greatest height, we still see among its coarse fibres nu- 
merous axis cylinders, in good preservation (Fig. 14). This 
preservation of the axis cylinders is considered almost dis- 
tinctive of disseminate (J. sclerosis by Professor Charcot. Charcot 
states that the axis cylinders have become hypertrophied ; this 
is a matter which appears open to question. 

Ganglion Cells. — The following description holds good for the 
ganglion cells in the entire cord. In the decidedly diseased 
portions there is a remarkable absence of processes ; but it hap- 
pens occasionally, even in a markedly sclerosed area, that a cell 
will be seen wh«>se process is apparently normal, and can be 
traced for a considerable distance ; most of the cells contain 
more or less yellow pigment, some are almost entirely filled with 
it, and no nucleus is visible ; in other cells the pigment is seen 
encroaching on the nucleus ; in some cells the nucleus is seen 
with clear and definite outline ; in many other cells they present 
an indistinct jagged edge, and occasionally they appear to be 
making an effort at budding. 

In some cells all the nucleus appears to have undergone a 
form of dissolution, as it presents a very broken appearance. In 
a number of cells the nucleus is displaced, sometimes almost 
into one of the large processes, in others to the extreme edge of 
the cell. In a markedly sclerosed area in the anterior horn of 
the cervical region, the cells have undergone a simple diminution 
in size, so that they are reduced to at least one-third. The cells 
in the columns of Clarke have undergone the same changes. 
The alteration in the cells is greatest in Case II. 

Vessels. — In Case I. the muscular coats of the arteries are very 
much hypertrophied, there is also some increase in the intima 
and adventitia and an increase in the number of nuclei ; the 
lumen of the artery is therefore rendered much smaller than 
normal. (Fig. 15.) 

In Case II. the arteries have also undergone the same changes ; 
although the muscular coat is not nearly as much hypertrophied, 
and the lumen of the artery is much larger. 

In comparing the arterial changes in these two cases we find 
that in Case I. the arterial change is greatest, and the sclerosis 
less marked, whilst in Case H. the sclerosis is most decided and 
the arterial change much less. 

The nuclei of these branching cells are very sharply stained 
by the hematosin, whilst the body is very lightly stained ; they 



DISSEMINATED CEREBROSPINAL SCLEROSIS. 273 

have slightly granular contents ; these nuclei present the same 
appearance at all stages of the process. The cells contain one, 
two, three and even four nuclei of irregular shape ; and often 
nuclei are seen with partial constrictions on thern as if they 
were about to divide ; the nucleus is most usually placed to one 
side of the cell. The processes which are given off from these 
cells are very numerous, and always leave the cell by a broad 
base, tapering off to a hair-like extremity, which becomes lost in 
the surrounding tissue. The shape of the cells, and the manner 
in which the processes are given off, varies very much ; some 
cells are to be seen with only two processes, one at each end. 

Other cells have a rather long body, and many processes given 
off from each end ; but the majority of cells have processes from 
all sides. Two of the cells seen are of enormous size, having a 
process of very great thickness, which can be seen for quite a 
distance and does not taper off like the other processes. (Fig. 16.) 

There are besides these branching cells small nuclei in more 
or less large number and of a variety of shapes ; but mostly 
round and sharply stained. These curious branching cells have 
been seen by other observers. Lubimoff* and Mierzejewskif have 
described them in the cerebral substance of general paralytics, 
Charcot and Gombault in a case of syphilitic disease of the pro- 
tuberance, Pierret in a case of myelitis. Debove appears to 
have seen them in a sclerosed patch of the ependyma ventricu- 
lorum. They are to be seen in a case of central myelitis with 
cavities from a patient of mine. 

They have been figured by JastrowitzJ in an article on " Study 
of Encephalitis and Myelitis in young children." Adler§ has 
also figured them. The cells figured by Jastrowitz are very 
similar to those seen by us. Mierzejewski describes these cells 
as being connected with the walls of blood-vessels. We have 
observed them in the vicinity of blood-vessels and sending their 
processes towards them, but it is very difficult to determine in 
this case whether they unite with the wall of the vessel or not. 
They have no special predilection for the neighborhood of ves- 

* Lftibirr.off , Beitraege zur patholog. Anatomie der allgem. progressiven Paralyse, 
Arcliiv fur Psych, und Nervenlc, Band 4, p. 579, 1874. 

f Mierzejewski, Etudes sur les lesions cerebrales dans la Paralysie Generale, 
Archives de Physiologie, Tome. 2, 1875; 2d Series, p. 195. 

% Jastrowitz, Arcliiv fur Psych, und Nervenkranklieiten, Band 3, 1872, p. 162. 

§ Adler, Ueber einige path. Veraenderungen an den Hirngefaessen Geistes- 
kranken, Archiv fur Psych, und Nervenkranklieiten, Band 5, 1875, p. 77. 
18 



274 DISSEMINATED CEREBROSPINAL SCLEROSIS. 

sels, but are to be seen everywhere. Pierret describes them as 
anastomosing ; we have not seen any anastomoses between our 
cells. 

Frommann figures, in sclerosis of the cord, cells somewhat 
similar ; but they have fewer processes and are very much 
smaller than the cells observed in our cases ; 500 to 950 diam- 
eters made them distinct ; their protoplasm is not so abundant. 

The interest attaching to these cells is in knowing if they are 
normal elements of the neuroglia which have become hyper- 
trophied. In looking over the records of pathological cases 
which have preceded, and the many recent observations in 
normal histology of the neuroglia, there appears good reason for 
believing that these are really normal elements of the neuroglia 
which have become hypertrophied. The cells, with hair-like 
processes, figured by Boll* and Deiters. Those depicted by 
Frommann, although containing a much larger number of fine 
processes and a nucleus surrounded with very little protoplasm, 
might be supposed to have undergone a modification so as to 
present the appearances of our cells. 

Butzket figures cells with processes from the normal neu- 
roglia, which, on the whole, have a much closer resemblance to 
the cells just described by us than any others we have seen. 
His cells have a good-sized nucleus with a considerable amount 
of protoplasm around them, and numerous fine processes with 
one or two large ones which do not taper off to fine points, and 
resemble very much the large one figured by us, as seen in the 
posterior part of the lateral column in the cervical region. 



Explanation of Figures. — Figures 1 to 11. Sections from various regions of 
both spinal cords, showing the various distribution of the sclerosed patches. 
Verick No. 2. Eye piece 3. 

Fig. 12. A neuroglia cell in the white matter of the spinal cord ; increase in 
the size of the nucleus, with an enormous increase of the protoplasm around it. 
1st stage. 

Fig. 13. From a section through the corpus striatum ; a large number of 
branching cells are seen distributed in a somewhat coarse mesh of neuroglia fibres; 
one or two cells proper to the corpus striatum undergoing degeneration. 2d stage. 

* Boll, Die Histiologie und Histiogenese der nervosen Centralorgane, Archiv 
fur Psych, und Nervenkrankheiten, Band 4, 1874, p. 1. 

f Butzke, studien ueber den feineren Bau der G-rosshirnrinde, Archiv fur Psych, 
und Nermnkrankheiten, Band 3, 1872, p. 575. 



DISSEMINATED CEREBROSPINAL SCLEROSIS. 275 

Fig. 14. Section from the brain; axis cylinders without a trace of myeline, 
lying in a very coarse, loosely arranged neuroglia fibre; a few branching cells 
showing all stages of degeneration. 3d stage. 

Fig. 15. Showing transverse section of artery with hypertrophied muscular 
coat, and an increase of nuclei in all the coats. 

Fig. 16. A very large branching neuroglia cell seen in the white matter of the 
cord ; two nuclei are to be seen, one of which shows a constriction in the middle as 
if it were about to divide. Verick No. 7. Eye piece No. 3. 



A CLINICAL LECTUEE ON SYPHILITIC CEEEBEAL 

LESIONS* 

1. Syphilitic Aeteehts ; 2. Tumoe of the Beain. 

Gentlemen : The first patient whom I bring before you to- 
day, I introduce merely for the purpose of exhibiting to you in 
an exaggerated form a symptom which is also seen in the next 
patient, who is suffering from some cerebral affection of very 
obscure origin, and upon whose case I wish to dwell somewhat 
more at length. This symptom is increased reflex movements ; 
and in the present instance they are certainly phenomenal, being 
much more marked than in any case which I have as yet had an 
opportunity of bringing before you. The man had hemiplegia 
two years ago, and since then reflex muscular action has been 
most extraordinary. You are probably all familiar with the 
reflex movement that is caused by striking the leg a sharp blow 
just below the patella when the limb is flexed and allowed to 
hang in a relaxed condition ; and you perceive how very exag- 
gerated the motion is here when the experiment is tried, the 
slightest tap, such as would scarcely kill a fly, being all that is 
necessary to produce it. In the upper extremity the same 
strongly marked phenomena are exhibited when the tendons of 
the flexor longis pollicis, biceps, triceps, and other muscles, are 
thus lightly touched. t 

* Reported by P. Brynberg Porter, M. D. Reprinted from the New York Medi- 
cal Journal, September, 1878. 

f This symptom — increased tendon-reflex— has recently been brought into prom- 
inence by Profs. Westphal and Erb in Germany, and I have followed their re- 
searches with much interest. I had this same patient before you last autumn, and 
tried the experiment of freezing the skin over the ligamentum patelke, and then 
tried the test. .The reflex contractions of the quadriceps were then just as well 
marked as before the freezing, showing that the sensory nerves concerned in the 
act were not cutaneous but tendinous. It is interesting to note that, since the 
clinical observation of Westphal, nerves have been discovered in tendons. The 
meaning of increased tendon-reflex I do not hold to be specially or specifically use- 
ful in practice. It simply is one more means of determining increased spinal ex- 
citability. Prof. Westphal has claimed that absence of tendon-reflex at the knee 



SYPHILITIC CEREBRAL LESIOXS. 217 

I pass now to the second patient, whose case, I think, we shall 
find a very interesting and instructive one. 

The man's name is Peter R . an Irishman, thirty-seven years of age. 

Fifteen months ago he had a chancre, which did not appear until a month 
after exposure, but which lasted for a considerable time. Six months later, 
blotches, which did not itch, appeared upon the skin, but no other signs of 
syphilis became developed. This is not, perhaps, a very satisfactory history 
of specific infection, but it is, at all events, as clear as we ordinarily obtain 
from hospital and dispensary patients, and so I think we shall have to accept 
it as such. "With the exception of this eruption, he remained well until Sep- 
tember last, when he noticed a weakness of the right leg. There was slowly 
developing paralysis in this extremity, which continued to increase until 
about November, since which time there has not been much change in the 
condition of the limb. The paralysis also affected the upper extremity on the 
right side, and about a month ago the grasp of the right hand indicated, in 
three trials, the numbers 35, 35. and 34 respectively upon the scale of the 
dynamometer, against 40, 40, and 3G respectively marked by that of the left 
hand. In addition, there has been right facial paralysis and some little im- 
pairment of memory. He has never had any injury to the head, nor does he 
suffer from cephalalgia. There is nothing wrong about the eyes, as far as can 
be detected by the ophthalmoscope, and the urine has also been examined 
with a negative result. Finally, speech is entirely normal, there being no 
evidence of any kind of aphasia. One week ago a new and important symp- 
tom showed itself, and that is. weakness of the other lower extremity. There 
has also now become developed, for the first time, increased reflex. In this 
instance it affects not only the muscles, but the bladder and other organs in 
addition ; in other words, it is both tendinous and visceral. Formerly it was 
erroneously supposed that in such cases there was real paralysis of the blad- 
der, and such is the vague sort of impression still prevalent among many of 
the profession ; but about twenty years ago, Brown-Sequard demonstrated 
conclusively that frequent, interrupted, involuntary escape of urine from the 
bladder was due merely to reflex spasm. 

Xow let us look for a moment at the objective symptoms. The walk, you 
perceive, is not that of hemiplegia, lacking entirely the scythe-like leg move- 
ment so characteristic of that affection. This man drags his feet after him in 
a very slow and painful manner ; and while both the limbs are lacking in 
power, it is evident that the right one is considerably the weaker of the two. 
In walking he frequently staggers (though there is nothing especially signifi- 
cant about this), and he is unable to stand upon one leg. The naso-labial 
fold is much more distinct on the left side of the face than on the right, and 
the left pupil is slightly larger than the right. The tongue is found to devi- 
ate somewhat to the left, contrary to the ordinary rule in such cases, accord- 
ing to which it should incline toward the paralyzed side. The relative power 

(knee-phenomenon) is an early symptom of sclerosis of the posterior columns ; and 
I am pleased to say that observation upon several of my tabetic patients has con- 
firmed this. 



278 SYPHILITIC CEREBRAL LESIONS. 

in the two hands, as shown by the dynamometer, remains about the same now 
as it Avas a month ago. As far as we are able to make out, therefore, the case 
presents the symptoms of double, incomplete hemiplegia. There is also in- 
creased reflex in the muscles, which, though not so extraordinary as in the 
first case I showed you, is still exceedingly well marked, and, as you perceive, 
is much stronger upon the right side than on the left, both in the upper and 
lower extremity. 

The next question that arises is, which is the situation of 
the lesion, or rather lesions, which have produced the phe- 
nomena noted ? If these had been in the anterior lobes of the 
brain and near the island of Eeil or the third convolution, 
we should have had some interference with speech ; and' it is 
equally certain that they cannot have been in the posterior 
lobes' The first lesion is, no doubt, to be looked for in the 
middle portion of the left hemisphere, and the second in the 
corresponding part of the right hemisphere. I think we can 
exclude here a lesion of the base near the median line ; for, 
when, this occurs, serious trouble ensues much more rapidly 
than has been the case in the present instance, and the cranial 
nerves are affected in a much more marked manner. 

Now, what is the nature of the lesion? When the nature 
of the attack that has occurred is taken into consideration, we 
must undoubtedly exclude both hemorrhage and embolism. 
As far as relates to the latter, moreover, I may mention that 
the heart is entirely normal. Again,- there does not seem to 
be any reason to suspect a diffused peri-arteritis, causing 
aneurisms from which might possibly result the symptoms 
present in the case. Syphilitic tumors of the brain are quite 
common; but if there were one at the base here, we should 
unquestionably have a lesion in the eye, such as choked disk, 
or neuro-retinitis. Let us, then, inquire whether we may not 
have here the form of arteritis sometimes met with in syphilis. 

Syphilitic arteritis is not degenerative, like atheroma of the 
vessels. It is true that some authorities are of the opinion 
that atheroma is proliferative at first. This view lacks proof, 
however, while there can be no possible doubt that syphilitic 
arteritis is essentially hyperplastic and proliferative. In the 
first place, you must remember that the lesion is a diffused 
one, affecting the arteries in the rest of the body as well as 
those of the brain. To speak more strictly, it is an endo-arteri- 
tis, the hyperplastic formation taking place on the inner surface 



SYPHILITIC GEBEBBAL LESIONS. 279 

of the vessel, and usually confined to one side of it. In some 
cases, however, the whole surface is affected in the same manner, 
and then the calibre of the artery becomes so diminished 
by this choking-up process as to finally be almost impervious. 
The deposit of inflammatory products is not uniform along the 
whole course of the vessel, but takes place irregularly at various 
points, so that a number of consecutive little tumors are thus 
produced. After a time the proliferation cells undergo fatty, 
but never calcareous, degeneration. By this choking of the 
arteries the supply of blood to the brain is much diminished, 
and sometimes we have the same result as occurs in embolism, 
viz. : parts of the brain become necrosed in consequence. In 
such cases recovery depends on whether a vital part of the 
brain has become affected or not. If the third frontal convolu- 
tion were involved, the patient would never recover his speech, 
although he might take any amount of iodide of potassium. The 
prognosis, as you may readily understand, is usually very grave. 

In the present case, however, the paralysis is so imperfect 
that there is room for considerable hope. No essential portion 
of the brain has probably as yet become affected ; but the re- 
sult, I would impress upon you, is still very uncertain. 

This syphilitic arteritis is a very recent discovery in medical 
science, and it was only in 1873 that Heubner first described it. 
Since then it has been suggested that we may possibly have a 
somewhat similar arteritis which is non-syphilitic ; but as yet 
there is not sufficient evidence to prove the point. Heubner 
says that the specific arteritis is as common as specific tumors 
of the brain ; but whether this is really the fact or not can only 
be determined by a more extended series of observations than 
there have as yet been time and opportunity for since the dis- 
covery was made. 

In the patient now before us we are led to exclude common 
tumor of the brain on account of the absence of three prominent 
characteristics of that condition, viz. : 

1. Choked disk. 

2. Convulsions. 

3. Localized pain in the head. 

On the other hand, the symptoms correspond perfectly with 
what we would naturally expect in the syphilitic affection of the 
cerebral arteries described ; and, as there has been a distinct 



280 SYPHILITIC CEREBRAL LESIONS. 

history of syphilis in the case, I think there can be no reason- 
able doubt of the correctness of our diagnosis. 

But the third patient, whom I now present to you by way of 
contrast (and I am very glad, indeed, to have the opportunity of 
thus bringing the two together for your observation), has all the 
three symptoms of tumor of the brain to which I have just 
called your attention. 

This woman is a widow, fifty years of age, a native of Ireland. Like many 
others suffering in a similar manner, she found her way to an eye infirmary, 
and it was through the kindness of my friend Dr. Webster, under whose care 
she came, that she was sent to me. The following is her history : One morning 
in the month of November, 1876, she found to her astonishment that she was 
paralyzed and numb on the left side. Her speech was also considerably 
affected, but was not lost. Afterward the paralysis very decidedly improved, 
but there was no change in regard to her power of articulation. At the same 
time she began to suffer from severe pain in the head and noises in the right 
ear. Her eyesight remained good for quite a long time, but became impaired 
about the beginning of February of this year. Dr. Webster, who examined 
her eyes at the Manhattan Eye and Ear Hospital, states that there is no 
diplopia or hemiopia, but that there is well-marked neuro-retinitis, with 
hemorrhages in the retinae, »and, in addition, incipient cataract in one eye. 
About ten years ago, just before her husband's death, the woman had a 
venereal wart, followed by the characteristic symptoms of constitutional 
syphilis, such as sore-throat and non-itching roseola. 

The impairment of vision, you will perceive, is quite a late symptom. The 
pain in the head, *on the contrary, has existed from the beginning, and lias 
always been more marked upon the right side. I regret that no thorough 
examination of the ear on that side lias been made. Yesterday the patient 
told me that within the last two or three months she has had several attacks 
of dizziness, accompanied with complete loss of speech. These lasted but a 
few moments, she says, and she thinks that she did not lose her consciousness 
in them. They seem to be epileptiform in character, as far as I am able to 
make out, but not to amount to real convulsions. I should like, however, to 
have the testimony of others besides that of the patient upon this point. 

On examining into her present condition, we find that she still suffers from 
a good deal of pain in the head, chiefly upon the right side, and that she has 
impaired vision with choked disk. In addition, the weakness upon the left 
side of the body still continues, and she now has attacks of temporary loss of 
speech. When she walks, her gait is very peculiar, there being a distinct 
falling of the whole side (left) in which the hemiplegia has occurred. There 
is no facial paralysis present, as you perceive that the naso-labial folds are 
equally distinct on the two sides. The strength of the left hand, as compared 
with that of the right, is indicated by the dynamometer, which marks for the 
former 17 and 18, and for the latter, 25 and 28, in two testings. 

Let me now direct your attention for a moment more particu- 



SYPHILITIC CEREBRAL LESIONS. 281 

larly to the lesion met with in the eye here, for it is one which 
I think all medical men should learn to recognize. In the nor- 
mal condition of the eye we get a very distinct outline of the 
disk. The margin is sharply denned, and not raised above the 
level of the surrounding retina. Indeed, it is sometimes actually 
depressed, and when this is the case it is denominated normal 
or congenital excavation. In neuro-retinitis, however, instead 
of the creamy color and sharp outline of the disk of the optic 
nerve, we find a swollen surface, not infrequently of a decidedly 
reddish hue, and without any distinct demarkation between the 
nerve and the surrounding retina. There are often blotches of 
hemorrhage on various parts of the retina, and sometimes in the 
disk itself. This condition is seen in the present case, and the 
nerve is also very decidedly protuberant here. 

As to the situation of the cerebral lesion in this case, we can 
only say that it is probably situated, somewhere in the middle 
portion of the right hemisphere, no more definite localization 
of it being as yet possible. As regards its nature, there can be 
little doubt that we have to deal with a tumor. In favor of its 
being such, we have the three points of localized pain in the 
head, choked disk, and attacks of loss of speech, which are in 
reality probably epileptiform seizures. If the patient had two 
lesions with aphasia, we should undoubtedly have other symp- 
toms which are now lacking. Next, as to the essential nature 
of the tumor, with the history that the patient presents, the 
probabilities are altogether that it is of syphilitic origin. In 
these specific tumors of the brain, which are technically called 
gummata, the new cells, formed at the expense of the connective 
tissue of the brain, are found very closely packed together ; and 
fatty degeneration is exceedingly apt to occur in those lying in 
the centre of the growth. 

One point seems a little difficult to understand, and that is 
why a patient with such a tumor of the brain should be taken 
with a sudden paralysis. But we must remember that most 
portions of the brain accommodate themselves in a very re- 
markable manner to any slowly increasing growth of this char- 
acter, and that it is often only after it has attained quite a con- 
siderable size, or produced some special irritation, that such a 
tolerance is no longer possible. When this point is reached, 
either paralysis or convulsions are apt to occur in a very sudden 
manner. 



282 ' SYPHILITIC CEREBRAL LESIONS. 

These two cases form a very interesting study when taken in 
connection with each other ; and in order to bring them more 
clearly together before yon, permit me to once more run briefly 
over the prominent points in the former one : The patient, a 
male, and thirty-seven years of age. Fifteen months ago he 
had constitutional syphilis, and six months ago right hemiplegia, 
gradually developed, and without aphasia or sensory disturb- 
ance. Recently there has been double hemiplegia, the left side 
being also affected, and with this, increased reflex. Finally, 
there has been no localized headache, no epileptiform seizures, 
and no lesion of the optic nerves. The diagnosis is syphilitic 
arteritis, and consequent localized cerebral softening. 

The prognosis in the two cases is very much the same, but 
probably somewhat better in that of the patient with the 
tumor than that of the one with arteritis. As regards the 
case of tumor, however, it is necessary to make the prognosis 
concerning the affection of sight separate from that in regard 
to the general condition; for there is great reason to appre- 
hend irreparable atrophy of the optic nerve. It is possible 
that the tumor may not prove fatal to the patient, though in 
a considerable number of cases such is the result. This case 
illustrates very admirably the utility of the ophthalmoscope 
in the study of nervous diseases, and we are now called upon 
quit® frequently to resort to it in troubles about the head. As 
instances, I may mention the cases of basilar meningitis occur- 
ring in children which I brought before you some little time 
ago, and in which it would have been quite impossible to make 
a correct diagnosis without the aid of this instrument. So, too, 
in Bright's disease and other affections, the instrument is often 
of the greatest assistance to the general practitioner, as well as 
to the specialist ; and I think that every medical man should be 
more or less familiar with its use. 



LECTURES ON THE LOCALIZATION OF SPINAL AND 
CEREBRAL DISEASES.* 

Lecture I. 

SUMMARY — INTRODUCTORY REMARKS — HISTORICAL CONSIDERATIONS CONCERN- 
ING LOCALIZATIONS IN THE SPINAL CORD — PHYSIOLOGICAL ANATOMY, AND 
PHYSIOLOGY OF THE SPINAL CORD. 

Gentlemen : — The Faculty having again done me the honor to 
assign to me' some of the extra Thursday Lectures this winter, I 
have chosen as a subject the very practical question of the 
Localization of Diseases in the SjDinal Cord and Brain. 

This topic is now engaging the attention of many of the best 
minds in the profession, and it is being made the object of care- 
ful observation and ardent controversy. Well-reported cases 
bearing on the question abound in the current medical liter- 
ature. 

The subject has two principal aspects. One of these, that re- 
lating to the doctrine of the localization of functions in the brain 
and spinal cord, is more especially interesting to the physiolo- 
gist and psychologist. The other aspect, that which concerns 
us as practical physicians, is with reference to the possibility of 
making an accurate diagnosis of the seat of the lesion in or- 
ganic diseases of the nervous centres. 

It is this second aspect of the question which I shall discuss 
with you ; and I shall endeavor to do it in as concise and prac- 
tical a manner as possible — in such a way, in short, as shall 
enable you to utilize in your future daily practice the various 
principles and propositions which I shall have the pleasure of 
presenting to you. 

In other words, the following lectures will be upon the rational 
diagnosis of cerebral and spinal diseases. 

In practice, when we have completed the examination of a 
patient, several questions are put to us by the patient, by his 

* Delivered at the College of Physicians and Surgeons during the months of 
December, 1877, and January, 1878. Reprinted from the Medical Record, vols, 
xiii. and xiv., 1878. 



284 LECTURES ON LOCALIZATION. 

friends, or by ourselves. These are in chronological order : Is 
there disease? Where is the disease? "What is the disease? 
What are we to do for the cure of the disease or for the relief 
of the patient ? Will the patient die or recover ? 

Of these questions the one which our client and the world at 
large consider the most important, is the fourth — that relating 
to treatment and cure. This preference is natural, but highly 
unscientific ; it is a manifestation of that untrained mental action 
which demands results and scorns methods, which welcomes 
empirical achievements (provided they be agreeable), and which 
conduces to the perpetuation of quackery of all kinds. But to 
the physician who is not a mere prescription- writer, who aims 
at infusing as much science into his practice as possible, and 
who believes that he is not in the world for the purpose of 
gratifying his patients at so much per visit, but that he owes 
himself a debt of training and self-culture, and who has a sincere 
regard for science — to such a physician the first three questions 
assume a justly great importance. Pray observe that I do not 
say paramount importance, but great importance. And the su- 
periority of the humanitarian over the scientific duty becomes 
less glaring if we bear in mind the truth — and I firmly believe it 
to be such — that success in treatment now depends, and in the 
future will still more closely depend, upon the scientific study 
of the human subject in health and disease. In other words, 
I would impress you with my own conviction that the best 
trained and most scientific physician, if he be not a closet- 
student and theorizer, is the best practitioner. 

We occasionally hear of an over-fine diagnosis, of extreme 
caution in the treatment of disease, and of the sweeping ajopli- 
cation of physiological laws to practice by men who are said to 
be " too scientific " ; but who can number the errors, nay the 
sacrifices of life, which must be laid at the door of the falsely 
so-called " practical men," who despise learning and scientific 
methods? Those of us who see something of the' rarer and 
more formidable kinds of disease fully realize that in medicine, 
as probably in other applicable sciences, ignorance leads to 
rashness and crudity in practice, while ripe knowledge conduces 
to success, or, at any rate, to caution in prognosis and expectancy 
in treatment. 

Of the three diagnostic questions : Is there disease ? What is 
the disease ? Where is the disease ? the second is the one which 



LECTURES ON LOCALIZATION. 285 

forms tlie key-note of these lectures. Where is the lesion pro- 
ducing the disordered actions or symptoms? The method to be 
followed in arriving at the solution of this question varies some- 
what in different departments of medicine. Some lesions can 
be seen by the trained unaided eye, or felt by the skilled hand ; 
the seat of others can be determined by auscultation and per- 
cussion, by the aid of instruments, such as the ophthalmoscope, 
laryngoscope, speculum, etc. But in the study of the nervous 
system greater difficulties are met with ; we are, to a great 
extent, deprived of these physical aids; we cannot appreciate the 
condition of the brain and spinal cord directly by our special 
senses, but only by a proper interpretation of the way in which 
the functions of these parts are performed. In other words, the 
diagnosis must be made chiefly by reasoning. 

What are the conditions or data necessary for correct reason- 
ing in nervous pathology ? An enumeration of these will be a 
brief statement of the way in which I purpose treating the 
questions before us. 

First, you should possess a knowledge of the physiological 
anatomy of the parts concerned, viz., the brain and spinal cord. 
You are not obliged, for this purpose, to know much of the his- 
tology of the nervous tissue, but you should understand the 
arrangement of its various parts as recently revealed to us by 
perfected anatomy and embryology. 

Second, you must be well versed in the mode of life and 
action, or physiology of the cerebro-spinal axis. You must 
understand, as well as the present state of science allows, what 
parts are excitable and what inexcitable, which transmit 
impulses and sensations, which receive impressions, which 
originate the motor impulse, and which are endowed with, spe- 
cial functions. 

Third, you need a thorough understanding of the perverted 
functions of the nervous system, and of other systems connected 
with it — i.e., of the symptoms of nervous disease ; you should 
cultivate semeiology. And it is here more especially that pre- 
vious general medical training is of great aid to the student of 
nervous pathology. 

Fourth, you must have a clear conception of the empirical 
knowledge already gained by numerous post-mortem examina- 
tions of persons who have died with disease in the nervous 
system. You should not accept every proffered autopsy, but 



286 LECTURES ON LOCALIZATION. 

critically analyze before making use of it. You may demand 
that it shall approximate a physiological experiment in exactness 
and in simplicity. 

Fifth, and not least, it is necessary that you have and use a 
keen critical and logical sense in the appreciation and combina- 
tion of the above normal and morbid phenomena, in order that 
you may arrive at sound inductions. 

The importance of the combination of the above notions for 
the study of nervous diseases is immense. Any hypothesis, to 
be acceptable, must be based upon anatomy, physiology, semei- 
ology, and pathological anatomy. The various crude theories 
which have reigned awhile in medicine were such as did not 
fulfill this requirement ; some of them were deductions from 
anatomical data, others applications a priori of physiological 
laws to medicine, others still based solely upon clinical studies, 
or upon autopsies. Indeed an effort is now being made to break 
down the growing doctrine of localization of lesions and func- 
tions in the brain by just such a one-sided argument. It is 
claimed by a high authority that facts of the fourth category 
(post-mortem examinations) contradict, in a perfectly over- 
whelming manner, the doctrine in question. Now, I trust that, 
however feebly I may handle the subject, I shall yet be able at 
the proper time to give you good reasons why we must decline 
to accept and apply that authority's facts as he does. 

Of the few who now deny that we can accurately localize dis- 
ease in small parts of the brain during the life of the patient, I 
would, finally, make this critical remark : Their seemingly 
crushing argument is based upon what seems to me a funda- 
mental error in the appreciation of natural phenomena, and that 
is, not making allowance for variability and mutability in the 
highly organized human frame. "We now, since the labors of 
Darwin more particularly, admit that species in the animal and 
vegetable kingdoms are not fixed forms, but that they may pass 
into one another by almost infinitely numerous and delicately 
graded varieties ; we know that the ultimate composition of 
high organic bodies (proximate principles like albumen) varies 
somewhat ; we are prepared to occasionally find (passing to the 
human organism) the viscera transposed, or to meet with an 
exanthematous fever without its rash, with a pneumonia unac- 
companied by expectorations, or with a painless peritonitis, etc. ; 
in other words, we are, as naturalists and physicians, ready to 



LECTURES ON LOCALIZATION. 287 

admit variability and irregularity in the organism. Yet in spite 
of all this general and special knowledge, the opponents of local- 
ization maintain that there can be no irregularity in cerebral 
action, and they say, by implication at least, that the decussa- 
tion of the anterior pyramids must always take place, and be 
total. They demand of those who believe in localization that 
they should be able to make every observed case harmonize with 
their generalizations. Is this reasoning fit to be applied to nat- 
ural history ? Are we prepared to make use of the mathematical 
method in pathology? 

I shall treat, first, of localizations in the spinal cord and 
medulla oblongata; and, second, of localizations in the brain 
proper. 

I take up the spinal cord and medulla first because the phe- 
nomena are there more simple, and there is less controversy 
about them than there is with reference to the brain. 

HISTORICAL CONSIDERATIONS. 

The now voluminous literature of diseases of the spinal cord 
does not teach us much with respect to the localization of its 
diseases. The writers of the end of the last century and of the 
first quarter of this — Frank, Sauvages, Rachetti, Abercrombie, 
Ollivier — adopted a pathological classification, which has been 
generally followed in systematic treatises since. Frank recog- 
nized, in a pretentious section of his great work on medicine, 
only spinal neuralgia (rachialgia), myelitis and spinitis (rachial- 
gitis), and hydrorachis. Ollivier, in his last edition, 1837, en- 
larges greatly upon this primitive list, and describes at least 
eleven morbid conditions of the spinal cord and its membranes. 
Brown-Sequard, in 1861, besides demonstrating, as he thought, 
the existence of reflex paraplegia, treats of all diseases of the 
spinal cord briefly, and makes an attempt at localizing lesions. He 
admirably points out how we can diagnosticate a lesion occupy- 
ing one-half of the spinal cord (henii-paraplegia and spinal 
hemiplegia), and also how the height of a lesion in the cord may 
be estimated. Besides he makes the first attempt at localizing 
disease in one of the columns of the cord, saying that when the 
anterior columns are alone inflamed there is paralysis without 
anaesthesia and little dysesthesia. He (not knowing of Turck's 
researches) doubts the pathological independence of locomotor 
ataxia. 



288 LECTURES ON LOCALIZATION. 

In 1864 appeared Jaccoud's excellent book, which chiefly 
treats of semeiology and aetiology of spinal diseases. He makes 
an advance upon previous writers, by considering the question 
of diagnosis of location of the lesion quite fully, and reaching 
the following conclusions : 1. Disease in the anterolateral col- 
umns produces palsy without alteration of sensibility ; 2. There 
are no symptoms clearly indicating disease of the anterior gray 
matter alone ; 3. It is easy to recognize if the sesthesodic tract 
is diseased (sclerosis of the posterior columns) by pain, increased 
reflex, " and anaesthesia ; 4. Lesion in one-half of the cord low 
down is indicated by hemi-paraplegia, high up by spinal hemi- 
plegia. Leyden, writing in 1874^6, adopts the usual patho- 
logical classification, and his work is an admirable treatise. He 
in numerous places refers to the localization of lesions in the 
posterior columns, the lateral columns, the anterior cornua, the 
centre of the cord, and the nuclei of the medulla oblongata, point- 
ing out the diagnosis of each. Hammond, 187G, gives a good 
resume of the state of knowledge on the subject, basing his classi- 
fication in part upon notions of localization. 

But it is to monographs that we owe most in this branch of 
pathology. 

In 1851 Tiirck demonstrated the extent and exact distribution 
of descending degeneration in the spinal cord secondary to 
cerebral lesions, and in 1857 he found the lesion in locomotor 
ataxia (then called tabes dorsalis) to be sclerosis of the posterior 
columns; Dr. J. Lockhart Clarke discovered the lesion of pro- 
gressive muscular atrophy in 1861-2 ; Prevost that of infantile 
spinal paralysis in 1865 ; Prof. Charcot that of progressive labio- 
glosso-laryngeal paralysis in 1868 ; in 1865 the same observer 
published an autopsy of a case of sclerosis of the lateral columns 
(three others had been published by Tiirck in 1856), and in 
1875 Prof. Erb, of Heidelberg, and Prof. Charcot delineated the 
clinical features of this disease — spasmodic tabes, or spastic 
spinal paralysis. In 1874 Charcot described a mixed type, in 
which disease of the anterior gray matter is combined with scle- 
rosis of the antero-lateral column — amyotrophic lateral sclerosis. 
Disease in the central gray matter has been well studied by 
Hallopeau 1869-70, and Schuppel, and by Leyden, 1876. Dur- 

* This word is used in a substantive sense, in imitation of German writers, to 
designate reflex movements. I think that the word is now much used orally by 
clinical teachers in this way. 



LECTURES ON LOCALIZATION. 289 

ing the present year Prof. Flechsig has begun the publication of 
a series of papers upon the systematic diseases of the spinal 
cord, a work of the greatest merit, based in greater part upon 
the author's own pathological observations, and upon his yet 
more important embryological and microscopical studies upon 
the structure of the spinal cord (1873-6). 

As regards the diagnosis of the location of non-systematic 
lesions (focal lesions) of the spinal cord we have made no mate- 
rial advance upon the data given us by Brown-Sequard in 1861. 

Let us now briefly review so much of the anatomy of the spinal 
cord as is indispensable to the study of the localization of its 
functions and lesions. I shall take it for granted that you are 
acquainted with the usual descriptive anatomy of the nervous 
centres, and call your attention chiefly to their physiological 
anatomy. 

The spinal cord is a mass of white and gray nervous matter 
disposed lengthwise in columnar form, and varying in relative 
proportions at various points. This finer arrangement of the 
gray and white columns is best studied in transverse sections 
made at different heights in the spinal cord — for example, 
through its upper cervical part, through the cervical enlarge- 
ment, through the lower dorsal region, through the middle of 
the lumbar enlargement, and near the end of the cord. In every 
such section we find the same parts, white and gray, but the 
shape of each is very different on the various surfaces. In gen- 
eral terms the gray substance, or vesicular neurine, is disposed 
in the centre of the section in the shape of an irregular letter H, 
with clubbed ends forward. These ends, anterior and posterior, 
are called horns ; they are symmetrical on either side of one 
section, and the posterior reach out to the very periphery of the 
cord, dividing the inclosing white substance of each half of the 
section into two parts, the posterior column and the antero- 
lateral column. By means of pathological study, by histology, 
and more especially by means of embryology, these white col- 
umns have been much more subdivided. Following the latest 
arrangement by Flechsig, we find in each lateral half of a trans- 
verse section of the spinal cord the following parts, proceeding 
from behind forward : 

1. A small triangular column of varying size, lying next to the 
posterior median septum, in contact with its fellow of the oppo- 
site side, the posterior median column, or column of Goll. 
19 



290 



LECTURES OK LOCALIZATION. 



2. Externally to this, lying between it and the inner margin 
of the posterior gray horn, is a broad band containing the sensory 
fibres of the posterior roots, the posterior root zone, or zone 
radiculaire posterieure (Charcot), or column of Burdach. These 
two constitute the posterior column of the simpler classification. 

3. A small zone lying next to the periphery of the cord, just 
anterior to the apex of the posterior horu — the direct cerebellar 
column. 

4. Between that and the body of the posterior horn lies an 
ovoid mass of fibres, the crossed pyramidal column — derived 
from the opposite cerebral hemisphere by way of the anterior 
pyramid. 

5. Anteriorly to these two, occupying the sides of the section 
and reaching inward to the gray matter, we find the lateral col- 



umns. 



6. Lying in front of the anterior gray horns, and extending 
forward to the periphery, is the zone radiculaire anterieure (Char- 
cot), or anterior fundamental column. 




7j \7 ] 
A 

Fig. 1. 
Transverse section of the spinal cord.— A. Anterior median fissure; P. Posterior median septum ; 
1. Columns of Goll ; 2. Columns of Burdach ; 3. Direct cerebellar column ; 4. Crossed pyra- 
midal column ; 5. Lateral column ; 6. Anterior fundamental column ; 7. Direct pyramidal col- 
umn : 8. Posterior gray horns ; 9. Anterior gray horns. Stippled part = gray matter. Shaded 
part = sesthesodic system. Unshaded part = kinesodic system. 

7. A strip of white matter lying on the margin of the anterior 
median fissure, extending quite to its bottom, is the column of 
Tiirck, or better, the direct pyramidal column — derived from the 



LECTURES ON LOCALIZATION. 



291 



cerebral hemisphere of the same side, by way of the anterior 
pyramid. 

The simple division of the gray matter into 8, the posterior 
horn, 9, the anterior horn, will suffice for our purpose. In the 
accompanying wood-cut the above subdivisions are indicated by 
numbered spaces. 

In an equally aphoristic manner allow me to recall to you the 
chief physiological attributes of the spinal cord : 

1. It is an organ for conduction. Conduction takes place in 
two directions ; centrifugally for motor impulses, and centripe- 
tally for sensory impressions. The paths (I will not say 
fibres) for sensory impressions ascend only a very small distance 
in the posterior columns (columns of Burdach) before they enter 
the gray matter, and there at once pass over to the opposite 
half of the cord (in man at least). Consequently we say that the 
conductors of sensation decussate in the spinal cord throughout 
its whole extent. Motor paths, on the contrary, in the spinal 
cord proper, remain in one-half of the organ white and gray 
matters ; they have already decussated (in part) at the crossing 
of the pyramids. A strange fact to be borne in mind is that 



M* 



Fig. 2. 

Course of motor and sensory paths in the spinal cord, after Brown-Sequard.— D. Decussation of 

pyramids ; M. Motor paths ; S. Sensory paths. 

very little gray matter may suffice to transmit all sensations. 
The illustration (Fig. 2) represents, after Brown-Sequard, the 
course of sensory and motor conductors. 

2. The excitability of various parts of the spinal cord is a 
point of some interest. It has been quite well settled that no 



292 LECTUBES ON LOCALIZATION. 

part of the healthy spinal cord is excitable, except the posterior 
columns ; though very lately Professor Yulpian has discovered 
traces of excitability in the internal part of the anterior column. 
However, in morbid states, a great change occurs, and even the 
unquestionably inexcitable gray substance becomes excitable, 
giving rise to various morbid sensations and to spasm. 

3. The spinal cord has an autonomy of its own, giving rise to 
reflex motor impulses, and producing others spontaneously. It 
is also probable that sensory impressions are rendered more per- 
fect in the spinal gray matter, but I am indisposed to attribute 
consciousness to it. This organ furthermore presides over (ex- 
ecutes) many automatic acts, many of them highly complex ; 
such as walking, swimming, standing, to a certain extent eating, 
dressing, playing upon musical instruments, etc. Part of the 
spinal gray matter is sloAvly and painfully educated to perform 
these actions, and can afterwards do them without any marked 
cerebral interventions. 

4. Besides, the spinal gray matter is supposed to possess a 
trophic function, to preside over the nutrition of muscles and 
other tissues, partly through the blood-vessels, and partly 
directly. This question is under discussion, but the fact remains 
that disease of the anterior gray matter produces marked atrophy 
of muscles, and may cause joint-lesions. The spinal cord is also 
said to embrace several so-called centres ; a genital or genito- 
urinary centre in the lumbo-dorsal region, a cilio-spinal centre 
in the lower cervical region, and various subordinate vaso-motor 
regions ; of these I recognize only one as useful in such a study 
as the one we are beginning, viz., the cilio-spinal centre (Budge, 
Waller, Brown-Sequard). There is a part of the spinal cord (in 
each of its halves), extending from the fifth cervical vertebra to 
the second dorsal vertebra, which contains vaso-motor nerve- 
fibres for the corresponding side of the neck, face, and eye. It 
also contains fibres whose normal action is to cause a dilatation 
of the pupil. In estimating the height of a lesion in the spinal 
cord a knowledge of the location of this cilio-spinal centre is of 
real utility. 

To sum up the physiology and anatomy of the spinal cord, I 
may divide its section-surface into two great territories, as indi- 
cated in Fig. 1. The larger part not shaded, embracing the 
anterior horns and all the antero-lateral columns, may be desig- 
nated as the kinesodic system, and the smaller shaded portion, 



LECTURES ON LOCALIZATION. 293 

including the posterior horns and the posterior columns, as the 
sesthesodie system. As the names imply, the latter system con- 
veys and receives sensory impressions, while the former trans- 
mits and originates motor impulses, and possibly is trophic in 
function. 

In the next lecture I shall systematically treat of the local- 
ization of disease in these physiological and anatomical sub- 
divisions of the spinal cord ; first in the two systems, and second, 
in each column or horn within each system. 



Lecture II. 

SYNOPSIS. — SYSTEMATIC LESIONS OP THE SPINAL CORD ; LESIONS IN THE 
iESTHESODIC SYSTEM, LESIONS IN THE KINESODIC SYSTEM. 

Gentlemen : — As a basis for our study of the diagnosis of the 
location of lesions in the spinal cord, I offer you the following 
classification, which I think embraces all that sound clinical ob- 
servation and post-mortem examination will justify us in diag- 
nosticating with certainty. 

I. Systematic Lesions of the Spinal Cord. 

II. Non-systematic or Focal Lesions of the Spinal Cord. 

By the former we are to understand pathological changes 
which involve one of the gray or white columns of the cord for 
a part or the whole of its extent up and down, without extension 
to adjacent columns. Such lesions are almost alwa}^s symmet- 
rical in the two halves of the organ ; and occasionally more than 
one such lesion may be present. 

By the second form of lesion we understand a focus of dis- 
organization or new tissue growth involving the spinal cord in a 
limited part vertically, and invading diverse columns, ' or even 
systems, transversely. These are the lesions en foyer of French 
authors. 

The first group may be subdivided as follows : 

I. Systematic Lesions of the Spinal Cord. 

a. Lesions in the iEsthesodic System. 

1. Sclerosis of the Columns of Goll. 

2. Sclerosis of the Columns of Burdach. 

b. Lesions in the Kinesodic System. 

1. Sclerosis of the Anterior Columns. 

2. Sclerosis of the Lateral Columns. 



294 LECTURES ON LOCALIZATION. 

a, with changes in Anterior Horns. 

3. Degeneration of the Posterolateral Columns. 

4. Myelitis of the Anterior Horns. 

5. Degeneration of Ganglion Cells of Anterior Horns. 

6. Central Myelitis. 

In studying the above forms of disease, I shall apply more or 
less rigidly the following method : 

First ; state the general symptoms which indicate disease in 
the part of the spinal cord (the system) affected. Second ; ac- 
curately locate the lesion, and state the symptoms produced by 
it particularly. Third ; say a few words concerning the disease 
in question. 

a. Lesions in the aesthesodic system are characterized by the 
following symptoms : Pain, usually of a peculiar kind, hyper- 
esthesia, numbness, and anaesthesia ; by a peculiar disorder in 
voluntary movements, viz. : ataxia ; and, negatively, by the ab- 
sence of true paralysis or spasm in the affected limbs. 

1. Sclerosis of the columns of Goll, or the posterior median 
columns. Whether in the ascending secondary degeneration, or 
idiopathically produced (one case), the lesion occupies the more 
or less exactly triangular space lying between the columns of 
Burdach. At the lowest part of the cord the lesion is hardly 
visible, owing to the smallness of the columns at this point, but 
in the cervical region it is quite large and distinct. At the cala- 
mus scriptorius the lesion disappears, and so far has not been 
traced higher up. In Pierret's case these columns were sclerosed 
throughout their whole extent. In cases of ascending secondary 
degeneration they are affected only above the focus of disease. 

The common lesion of the columns of Goll (secondary degen- 
eration) gives rise, so far as we now know, to no symptoms ; 
consequently, we can only infer its presence by determining the 
existence of a lesion capable of producing ascending and descend- 
ing degeneration in the spinal cord. 

The symptoms in the single case of idiopathic disease of these 
columns (Pierret's) are too uncertain and too badly reported to 
be of any use. They consisted in numbness, slight anaesthesia, 
and a tendency to retropulsion. 

It is right to conclude that we cannot to-day directly diag- 
nosticate disease limited to the columns of Goll. 

2. Sclerosis of the columns of Burdach, or the posterior root- 
zones. The lesion begins in the outermost portion of these 



LECTURES ON LOCALIZATION. 295 

columns, near the inner margin of the posterior horns, and, 
extending forward and inward, ultimately occupies the whole of 
the columns of Burdach, as shown in the accompanying diagram. 
The section showing this lesion, which I now pass around, 
was taken from the cervical enlargement of the spinal cord of a 
woman who had typical locomotor ataxia in the lower and upper 
extremities, gastric crises, diplopia, and amblyopia. In most 
fully developed cases of locomotor ataxia the sclerosis is found 
to occupy the posterior median columns as well, i.e., the whole 
of the posterior columns are degenerated ; but, since the re- 
searches of Pierret upon the functions and pathological anatomy 
of the posterior median columns, we must look upon changes in 
them as secondary to the sclerosis of the columns of Burdach. 




K 

Fig. 3.— location or essential sclerosis in locomotor ataxia. 

In complicated cases of sclerosis of the posterior columns 
there may also be sclerosis of the lateral columns, or degen- 
erative changes in the central and anterior gray matter. 

The symptoms which are characteristic of sclerosis of the col- 
umns of Burdach are, in order of importance, pain, hyperes- 
thesia, ansethesia, ataxic movements. I can only, in these lectures, 
call your attention to the great diagnostic symptoms, and must not 
attempt to delineate the semeiology, etc., of any disease ; yet 
the above symptoms deserve more than a mere mention. The 
pains are peculiarly characteristic — nay, almost pathognomonic. 
They are of several varieties. First, sharp, lancinating cutane- 
ous pains, appearing in spots, usually circular or oval, in size 
from one to two inches in diameter, in any part of the limbs 
which are afterward to become ataxic. A few shootings may 
take place in one spot, or it may be the seat of pain for twelve 
or twenty-four hours. A capital point is the capriciousness with 



296 LECTURES OX LOCALIZATION. 

which the pains appear in any and all parts of the limbs — toes, 
thighs, calves, shins, etc. They are vagrant or vagabond pains, 
in sharp contrast to the fixed neural pain of neuralgia. Second, 
deep, boring pains ; and third, tearing or bruising deeper pains, 
affecting the articulations as well. These pains are also vaga- 
bond and capricious in their mode of appearance. They may 
exist for years without anaesthesia and ataxia showing themselves, 
and both patient and physician are apt to speak of the pains as 
" rheumatic," instead of as pathognomonic of an incurable dis- 
ease. Hyperesthesia accompanies and succeeds the pain, more 
especially in the patches of skin which are the seat of stabbing 
pains. During the paroxysm, and for hours afterward, the patch 
or patches are exquisitely sensitive, and hyperalgesia exists. 
Anaesthesia is said to be present very early in the disease, as 
well as later. In the former case it occupies patches of skin on 
the legs, arms, and trunk, according to the extension of the dis- 
ease. In the second case it is found under the feet, later in the 
legs, and may involve the whole of the lower (and upper) ex- 
tremities toward the close of the disease. 

The ataxic walk consists in a jerky, stamping gait, the ab- 
ductors and extensors acting over-forciblv ; the want of co- 
ordination affects large muscular groups, thus differing from 
chorea, paralysis agitans, etc. But a somewhat similar ataxia 
may be present in cases of intra-cranial disease, so that I would 
urge you to fall back upon the sensory symptoms for your diag- 
nosis. 

Many practitioners employ what they consider a sure and 
ready test for locomotor ataxia, viz., they bid the patient try to 
stand with his eyes closed. If he stagger or fall, he is said to 
have the disease. Now, I would have you all bear in mind that 
this test is worthless. Oscillating with closed eyes is a symptom 
common to many cerebral, spinal, and peripheral morbid states, 
as hysteria, myelitis, etc. I once artificially froze the soles of 
a patient's feet, and showed him in this amphitheatre with an 
excellent stagger when his eves were closed. He staggered be- 
cause his feet were anaesthetic, and that is one reason why hys- 
terical women and the bearers of myelitis do the same. We 
may safely put it in this way : patients with locomotor ataxia, 
at a certain stage, do stagger when their eyes are closed ; but, 
as the bearers of several other spinal diseases do the same, the 
sign has no special value. 



LECTURES ON LOCALIZATION. 297 

For many years, and even long after the patient is absolutely 
unable to stand, there is almost no paresis and no diminution 
of reflex or of electrical excitability in the affected extremities, 
unless the sclerosis extend forward into the gray matter. 

We ought, I think, to be able to correctly diagnosticate this 
lesion in its first stage, viz., when only pain and hyperesthesia 
are present. 

Historical Considerations. — The clinical history of locomotor 
ataxia has been fairly well known since 1835 or 1840 ; German 
physicians describing it in great part under the name of Tabes 
Dorsalis. Romberg, in 1853 (and earlier), gave almost a per- 
fect picture of the disease ; but it was reserved for Duchenne 
(1859-60) to recognize the value of the pains and of the ataxia, 
as distinguished from paresis, as cardinal symptoms. Although 
Duchenne's description of the affection has hardly been im- 
proved upon, it must be admitted that he knew nothing of its 
pathological anatomy, and was quite wrong in his explanation 
of the symptoms. Yet the lesion of locomotor ataxia, or tabes 
dorsalis, had already been discovered by Tiirck in 1857. Un- 
fortunately, he buried his remarkable paper in the Transactions 
of the Academy of Vienna ; and Gull (Sir William) independently 
made the same discovery in 1859. In France, Bourdon worked 
out the pathological anatomy in 1861, and since, our knowledge 
upon the point has grown enormously. The anomalies of loco- 
motor ataxia, both semeiological and pathological, have been 
best studied by Charcot and his pupils. In 1873, Charcot and 
Pierret published their cases demonstrating that the primary 
essential lesion of locomotor ataxia involves the columns of 
Burdach. 

b. Lesions in the kinesodic system are characterized by the 
following symptoms : Paresis or paralysis, spasm, and muscular 
atrophy ; and, negatively, by the absence of anaesthesia, or of 
marked and permanent pain or numbness. 

1. Sclerosis of the true anterior columns, or columns of Tiirck, 
or, best, the direct pyramidal fasciculi, has been known patho- 
logically since the publication of Turck's first papers in 1851. 
Its semeiology is, however, unknown. We can infer its existence 
in those cases in which we diagnosticate lesion No. 3 (infra), be- 
cause pathological anatomy shows us that the two lesions are 
usually simultaneous. 

2. Sclerosis of the lateral columns. The lesion consists in an 



298 LECTURES ON LOCALIZATION. 

increase of the neuroglia and atrophy of nerve-fibres in the lat- 
eral masses of white substance throughout a greater part or the 
whole of the spinal cord. It may exist alone as a primary lesion 
or may be associated with other (secondary) morbid processes, 
such as No. 4 {infra). 

The symptoms consist in progressive paresis of the lower 
limbs, and later of the upper, with increased reflex, and a teta- 
noid state of the extremities. There is very little sensory dis- 
turbance, never anaesthesia ; the paralyzed and tetanized muscles 
do not undergo atrophy ; and the bladder is not in the true sense 
of the word paralyzed. 

These symptoms have been designated by various names. 
Erb calls the symptom-group spastic spinal paralysis ; Charcot, 
spasmodic tabes ; and I would suggest the term tetanoid para- 
plegia or paralysis. Erb in 1875, and Charcot in 1876, Erb 
again this year, have fully described the clinical aspects of the 
disease. 

In 1873 I described, under the title of tetanoid pseudo-para- 
plegia, the symptoms of the semi-developed disease, of that 
transition period when the patient is still able to get about 
upon his morbidly stiffened limbs. I failed, however, to seize 
upon the whole clinical picture. 

The pathological anatomy of this affection does not as yet rest 
upon a firm basis. Turck in 1859 published three autopsies in 
cases of this sort, but their clinical features had not been 
worked out. In 1865 Charcot reported sclerosis of the lateral 
columns as the lesion found in a woman who had suffered from 
aggravated hysteria, with contractures of the extremities, for 
many years. In the essays of 1876-7 no other autopsies are 
recorded. 

2 a. Combination of lesion of the anterior horns with sclerosis 
of the lateral columns. Charcot, in 1874, first called attention 
to this complex systematic lesion, and designated the disease as 
amyotrophic lateral sclerosis. 

The cervical enlargement of the spinal cord being nearly 
always the first part affected, we observe that the symptoms 
appear first in the hands ; a paralytic atrophy setting in with 
considerable rapidity. Formication and fibrillary movements 
may be present. The atrophy resembles more that observed in 
myelitis of the anterior horns (No. 4) than in degeneration of 
the ganglion cells of the anterior horns (No. 5). In a short time 



LECTURES ON LOCALIZATION. 299 

a degree of rigidity appears in the upper extremities, and the 
legs become first paretic, later, rigid, and contractnred. This 
contracture may be greatly relaxed while the patient is in bed, 
but is exaggerated if he try to stand or walk. In consequence 
of great atrophy of the inter ossei, the " claw-hand " deformity 
may appear. As a rule, the muscles of the lower limbs do not 
waste. The bladder and rectum are not paralyzed, and no 
anaesthesia is observed. If the patient's life be prolonged, the 
disease invades the nuclei of the motor bulbar nerves, and to 
the above picture we have superadded the symptoms of labio- 
glosso-laryngeal paralysis. 

Cases of this kind had been observed prior to 1874, but it is 
Charcot who in that year first gave us a clear statement of the 
pathological anatomy and semeiology of the disease. The con- 
nection between the two lesions, disease in the anterior horns, 
and sclerosis of the lateral columns, is by no means understood, 
and it may be questioned whether they are pathologically re- 
lated.* 

3. Degeneration of the posterior part of the lateral column, or 
(better) of the crossed pyramidal fasciculus. The lesion occu- 
pies, in a transverse section, a part of the white substance which 
lies between the lateral column and the posterior gray horn. It 
is separated from the periphery of the cord by healthy tissue, 
the direct cerebellar fasciculus. This alteration of tissue is 
secondary to a lesion in parts of the nervous centres above the 
decussation of the pyramids ; in the anterior pyramids, the great 
motor tract in the basis cruris cerebri, the anterior part of the 
internal capsule, the nucleus caudatus, the convolutions com- 
prising the excitable districts of the cerebrum. Lesions of any 
of these parts cause what is known as secondary degeneration 
throughout the motor tract, to the lowest part of the spinal 
cord. Consequently, the lesion in the spinal cord is always (?) 
on the side opposite to that on which the primary, supra-spinal 
disease exists. Hence, also, we usually find descending degen- 

* Since this lecture was delivered, Prof. Flechsig, of Leipzig (in Archiv der 
Heilkunde, 1878, Heft 1), has made an elaborate critique of Charcot's cases and 
others, and claims that the lesion in the lateral columns is chiefly in the postero- 
lateral columns, as in descending degeneration from cerebral lesion, and that the 
nature of the lesion seems more like a degenerative than a sclerotic one. Flechsig 
suggests that future research may reveal a double lesion in the cerebrum, or, at 
any rate, in the upper part of the intra-cranial motor tract. This view seems to 
me well worthy of consideration, and a careful attempt should be made to verify it. 



300 LECTURES OJST LOCALIZATION. 

eration only jn one-half of the cord. It should be remembered, 
however, that, as a portion of the anterior pyramid of the me- 
dulla does not decussate, but descends as the direct pyramidal 
fasciculus, or column of Tiirck, we must expect to find in many 
cases a similar lesion of this fasciculus on the same side as the 
supra -spinal lesion (No. 1). For example, after a lesion involv- 
ing the great motor tract in the left hemisphere, we shall find 
descending degeneration of the crossed pyramidal fasciculus in 
the right half of the cord, and of the anterior column, or direct 
pyramidal fasciculus in its left half. 

The symptom characteristic of this morbid condition is the 
secondary contracture, or late contracture, which so often suc- 
ceeds attacks of hemiplegia, being superadded to paralysis or 
anaesthesia. This lesion may be complicated with No. 4, when 
atrophy of some of the paralyzed and rigid muscles supervenes. 

In briefly mentioning the historical data connected with this 
lesiou, I must again mention Tiirck, the great pioneer in the 
pathology of systematic lesions of the spinal cord. In 1851 and 
1853 he exactly described the crossed part of the lesion. An 
excellent study of this and other forms of secondary degenera- 
tion was made by Bouchard in 1866, under the direction of 
Profs. Yulpian and Charcot. Last year Flechsig published his 
remarkable researches upon the nervous centres, and more ex- 
actly defined the seat of both the crossed and the direct degen- 
erations. To Prof: Bouchard is due the credit of completing 
the clinical picture, by pointing out the value of the symptom 
contracture. 



Lecture III. 

1. SYSTEMATIC DISEASES OF THE SPINAL CORD, CONTINUED ; LESIONS IN THE 
KINESODIC SYSTEM. 2. NON-SYSTEMATIC OR FOCAL LESIONS OF THE SPINAL 
CORD ; LESIONS AT DIFFERENT HEIGHTS IN THE ORGAN. 

Gentlemen : — There remain for consideration a few of the sys- 
tematic lesions of the spinal cord. 

4. Myelitis of the anterior horns, or poliomyelitis anterior. 
Like all affections of the kinesodic tract, this affection is char- 
acterized by the predominance of motor symptoms and the 
absence of sensory ones. But we also meet with great trophic 
changes — muscular atrophy — in this disease. 



LECTURES ON LOCALIZATION. 301 

The lesion consists, as we know from the autopsies by Goin- 
bault, by Cornil and Lepine, and by Dejerine, in an inflammation 
of the anterior gray horns of the spinal cord, leading to atrophy, 
and even destruction of the motor (and trophic ?) ganglion-cells. 
The change in the cells is acute pigmentary degeneration. 

In those regions of anterior gray matter corresponding to the 
paralyzed parts, hardly any motor ganglion-cells remain. Other 
lesions are degenerative changes in the motor nerves, as far as 
their termination, and muscular atrophy, usually without fatty 
metamorphosis. 

The symptoms of the affection vary in the three varieties : 
acute, sub-acute, and chronic. 

a. In acute febrile poliomyelitis* anterior we observe a sharp, 
remittent or continued fever, lasting one or several days, ac- 
companied in many cases by pains in the limbs, and sometimes 
by slight numbness. This is followed, suddenly, as a rule, by 
extensive paralysis, the fever ceasing. The paralysis may affect 
all the limbs, or two of them, or one only ; it tends to diminish 
spontaneously to a marked extent. No anaesthesia is present, and 
but little numbness. Reflex movements are reduced or abolished, 
the bladder and rectum act normally, and there is no tendency 
to bed-sore. But other even more characteristic symptoms soon 
follow. In a few days the nerve-trunks in the severely palsied 
limbs lose their galvanic and faradic excitability, and the 
muscles, while ceasing to respond to the faradic current, contract 
slowly, and with abnormal formula, to the galvanic current— =we 
have the degeneration-reaction. A little later, after two or three 
weeks, the palsied muscles undergo rapid atrophy, an atrophy 
which is progressive if no recovery is to take place. Ultimately 
only one muscular group may remain paralyzed and atrophied, 

b. There is a non-febrile acute myelitis anterior. The patient, 
usually a child, is put to bed well, and awakes in the morning 
with one or more paralyzed limbs, with the subsequent symptoms 
as above. 

In these two forms are to be ranged nearly all cases of infan- 
tile spinal paralysis so-called, and many cases of the same disease 
occurring in the adult. 

c. d. Febrile and non-febrile sub-acute myelitis of the anterior 
horns differ from the above only in degree of acuteness and in 
rapidity of development, and need no detailed description. 

e. Chronic myelitis of the anterior horns is often mistaken for 

* See p. 84. 



302 LECTURES ON LOCALIZATION. 

progressive muscular atrophy ; yet a diagnosis, is, I think, 
frequently possible. Often in this variety of poliomyelitis there 
occur severe neuralgic pains in the limbs which are to undergo 
palsy and wasting. These phenomena, when they appear, weeks 
or months after the first symptoms, attack whole muscular groups 
at once, and we do not observe the fibrillary or fascicular 
wasting of progressive muscular atrophy. The reactions are 
like those found in the acute and sub-acute form. No anaesthesia 
appears. This rare form has been observed in children and in 
adults. 

It is only very recently that we have had a correct knowledge, 
clinical and pathological, of myelitis anterior. Prior to 1865, 
infantile spinal paralysis, though well known clinically (Heine, 
1840), was thought to be due to congestion of the spinal cord, 
etCo ; but in that year Prevost, working with Charcot, discovered 
the lesions in the anterior horns, and since numerous autopsies 
have yielded the same results. As regards the disease in the 
adult, it was correctly observed and classified as far back as 
1847 (Duchenne), arid in subsequent years by Charcot and 
others. Its pathological anatomy was not discovered until 1873 
(Gombault) and 1875 (Cornil and Lepine). Although we need 
more light upon the intimate nature of the pathological changes 
occurring in this disease, I believe it to be now quite firmly 
established in nosology. Its diagnosis should be readily made 
by all practitioners. 

5. Degeneration of the ganglion-cells of the anterior horns. 
As indicated by the name, the lesion in this affection is degener- 
ative rather than inflammatory. This is true in the sense that 
changes in the neuroglia are wanting as a rule, and that the 
molecular death of the ganglion-cells takes place very slowly. 
This is in marked contrast to the suddenness and extent of the 
lesion in No. 4. Ganglion-cells are found in every stage of 
transition from simple increase of normal granular contents to 
mere roundish masses of granules — granular bodies ; in some 
parts of the anterior horns not even vestiges of cells remain. 

The symptoms of this lesion are fibrillary contractions followed 
by atrophy. Sensory symptoms are wholly wanting as a rule, 
and in a few cases the wasting limbs are the seat of some 
neuralgic pains. There is at no time a true paralytic condition, 
since the loss of power is precisely in proportion to the de- 
struction of muscular tissue. 



LECTURES ON LOCALIZATION. 303 

The mode of occurrence of the atrophy deserves a remark. 
Whole muscles or muscular groups do not waste away rapidly 
as in No. 4, but the muscular tissue undergoes change, bundle 
by bundle, very slowly. It thus happens that we see one or 
two large fasciculi in a muscle quite atrophied, while the adjacent 
fasciculi of the same muscle are normal, or only show fibrillary 
contraction. Several months may elapse before a muscle is 
wholly atrophied. Another feature of the atrophy is that it 
attacks by preference certain muscular groups, as those of the 
hand, chest, thighs, etc. It also affects simultaneously, or nearly 
so, parts w T hich are symmetrical and homologous. If we examine 
the wasting muscles with the faradic current, we obtain yet 
another diagnostic sign : in this affection reaction to the faradic 
current is lost only in the absolutely atrophied muscles or parts 
of muscles. This loss of reaction is in direct proportion to the 
atrophy, whereas in myelitis of the anterior horns whole 
muscles and muscular groups lose their faradic reaction en masse, 
and this, too, often before any marked degree of wasting has 
appeared. By the latter test, by the distribution of paralysis 
and atrophy, and by the predominance of neuralgic pains in 
chronic myelitis of the anterior horns, we may nearly always 
distinguish it from progressive muscular atrophy. Of course, 
the two diseases are congeners, and their pathological relation- 
ship may even be closer than we now suspect. 

Cruveilhier, Aran, Duchenne, and Roberts admirably de- 
scribed the clinical aspects of this disease, and its naked-eye 
pathological anatomy. But it is to the very recent labors of 
Lockhart Clarke (1861-2), and of Charcot and his pupils, that we 
owe the exact determination of the lesion in the anterior horns 
of the spinal cord. It is also only within the last ten years that 
we have clearly distinguished pure muscular atrophy from the 
various forms of symptomatic atrophy. 

6. Central myelitis. An inflammation of the central parts of 
the spinal gray matter, involving the sesthesodic and kinesodic 
tracts, extending in some cases throughout the whole length of 
the organ. The proliferative changes and exudations result 
either in the formation of a central plug, or the development of 
a cavity, which is filled with clear fluid. The anterior horns 
and the various columns of the spinal cord are more or less 
involved through extension of inflammatory action, or by com- 
pression. As might be inferred from the above, the symptoma- 



304 LECTURES ON LOCALIZATION. 

tology of the affection is obscure and complex. Early in the 
disease, disorders of sensibility — as numbness, formication and 
pain, followed by anaesthesia — are prominent. Irregularly dis- 
tributed paralysis, with or without atrophy, is also present. The 
diagnosis in this early stage, which may last years, is next to 
impossible. When the disease is fully formed, we have quite a 
distinct symptom-group. The arms alone are sometimes paralyzed, 
atrophied, and anaesthetic, while the legs are the seat of abnor- 
mal reflex, even to the degree of tetanoid walk. In other cases 
we see a general paralysis and universal anaesthesia, with con- 
tracture of some muscular groups, paralysis of the bladder, and 
the appearance of bed-sores. If the cervical enlargement be the 
seat of diffused central myelitis, pupillary symptoms are seldom 
wanting, and the pulse is accelerated. The disease is eminently 
a chronic one, years being required for its full development. 

Historical considerations. — Ollivier (1836) observed and de- 
scribed central myelitis with formation of cavities, but not much 
was learned of the disease and its semiology until Schuppel pub- 
lished his paper (Ueber Hydromyelus) in 1885. Hallopeau, in 
1871-2, contributed a series of elaborate articles upon the sub- 
ject to the Archives Generates de Medecine, and in the last few 
years Westphal and Leyden have paid considerable attention 
to this rather rare form of disease. 

2. — NON-SYSTEMATIC OR FOCAL LESIONS OF THE SPINAL CORD ; LESIONS AT 
DIFFERENT HEIGHTS IN THE ORGAN. ' 

A variety of lesions may involve the whole or a large part of 
the spinal cord at a given level, extending transversely through 
its various columns. These are focal lesions, and chief among 
them we find, injuries of all kinds ; compression by bone or 
by a tumor ; transverse sclerosis ; transverse softening ; hemor- 
rhage in cord ; tumor in the cord, etc. 

The nature of the lesion is sometimes such (fracture of verte- 
brae) as to indicate at once the seat of injury to the spinal cord ; 
but in many cases the peculiarity in the symptoms is not due to 
the nature of the lesion, but to its location high up or low down. 
The diagnosis of this location is possible only by the aid of 
anatomical and physiological knowledge. 

The following diagram, made from data furnished by Mal- 
gaigne, may assist in estimating the height of a lesion. It indi- 
cates the point of origin of the important nerves and plexuses, 



LECTURES ON LOCALIZATION. 305 

and the seat of so-called centers relatively to the spinous pro- 
cesses of the vertebrae. 

In general terms we may say that these focal lesions give 
rise to paralysis, numbness and anaesthesia, to modifications of 
the reflex function, usually an increase ; that they cause paresis 
or paralysis of the bladder and the sphincter ani, and that they 
set up a great liability to bed-sores. This general sketch varies 
greatly from that of the symptoms of any of the systematic 
spinal lesions, except No. 6, central myelitis. This great dis- 
semblance is a necessary result of the difference in the location 
of lesions ; focal lesions involving kinesodic, aesthesodic, and 
trophic parts of the cord, and cutting off the inhibitory action of 
the encephalon (Setschenow), upon the spinal cord. 

I shall attempt to make clear to you the diagnosis of lesions 
placed (1) in the lower lumbar enlargement ; (2) just above the 
lumbar enlargement ; (3) in the mid-dorsal region ; (4) in the 
cervical enlargement, and (5) in the upper cervical region. 

1. Focal, transverse lesions in the lower part of the lumbar 
enlargement. The motor symptoms produced by such a lesion 
are paralysis of the muscles innervated by the sciatic nerve — 
those of the feet, legs, posterior aspect of the thigh and the 
nates. The sphincter ani will be weak or paralyzed ; the bladder 
unaffected. The reflex movements of the paralyzed muscles are 
reduced in force, or absolutely wanting ; wanting if the whole of 
the gray matter in the lower end of the cord is diseased in such 
a way as to destroy its functions. Dependent also upon this 
extent of lesion downward is the state of muscular irritability. 
If the condition be as just described, the paralyzed muscles 
undergo atrophy, and lose their faradic contractility. The sen- 
sory symptoms are various ; at the beginning of the disease 
(often before paresis) there is numbness in the soles of the feet, 
without anaesthesia. Later the numbness may appear in the 
whole foot, the calf, the posterior aspect of the thigh, and actual 
anaesthesia may supervene. If the soles of the feet lose their 
sensibility, the patient is no longer able to maintain his equi- 
librium when his eyes are closed. Another sensory symptom of 
importance is the cincture or band feeling, which, whether like 
a cord or like a belt round about the palsied parts, indicates (in 
accordance with the distribution of sensory nerves) the upper 
limit of the spinal lesion. Thus, in the condition we now study, 
the cincture feeling will not be about the waist or groin, but 
20 



306 



LECTURES ON LOCALIZATION. 



around the ankle, leg, or thigh. The above symptoms make up 
an incomplete paraplegia. 



Medulla. 




Hypoglossal N. 

Pneumogastric N. 
Phrenic N. 



Brachial plexus. 
|p^ — Ulnar nerve. 



Crural N. 



Sciatic N. 



Fig. 4. 



Relation of spinous processes of vertebrae to spinal nerves. After Malgaigne Traiie cTAnatomie 
Chirugicale, vol. ii., pp. 32-3. 

2. Focal, transverse lesions, situated just above the lumbar 
enlargement. Conduction to and from the brain is interfered 
with, but the gray matter of the lumber enlargement retains its 
functional activity in great measure ; hence we have a very dif- 
ferent semeiology from that described above. In addition to 
weakness in the feet, there is developed a more or less complete 
paralysis of the whole of the lower extremities, from the pubis 
down. The rectum and bladder are paralyzed, the latter show- 
ing defective action by slow, interrupted micturition, or by re- 
tention, while constipation expresses the rectal paresis. The 
reflex movements of the paralyzed limbs are usually exagger- 



LECTURES ON LOCALIZATION. 307 

ated, sometimes enormously so. This increase in reflex move- 
ments gives rise to the combined tonic and clonic movements of 
the paralyzed limbs, which Brown-Sequard years ago designated 
spinal epilepsy. This often seems spontaneous, when the pa- 
tient is in bed for example, but it is certain that peripheral irri- 
tations, whether from the contact of the bed-clothing or from 
fseces in the rectum, urine in the bladder, etc., always precede 
and cause it. The preservation and increase of reflex is owing 
to the continued (increased) activity of the lumbar gray matter 
below the lesion, and the cessation of cerebral inhibitory action. 
Dependent upon the former fact also, we observe that the par- 
alyzed muscles do not undergo positive atrophy, and that their 
electrical reactions are normal or exaggerated. Erections occur, 
and coition may be accomplished in these cases and in those to 
be described in the next paragraph. 

As regards sensory symptoms we have, as in No. 1, numbness 
and anaesthesia in the paralyzed parts, extending as high up- 
ward as the groins or waist. The cincture feeling is nearly 
always present, and is placed by the patients round about the 
body at the level of the hips, or waist just below the umbilicus. 
In some cases the cincture is incomplete, and the feeling is 
likened to a firm grip in the patient's side or hip. The above 
description is a picture of common, complete paraplegia. 

3. Focal, transverse lesions in the middle or iipper dorsal 
region. The motor and sensory symptoms produced by a lesion 
so placed are very similar to those just described, with the fol- 
lowing additions. The abnormal reflex movements are often 
more marked than in No. 2, and the cincture feeling, index of the 
upper limit of the lesion, is placed at or above the umbilicus, 
around the lower ribs, or even just under the arms. In this 
condition the rectum and bladder may after a while partly 
regain their functions ; i. e., their contents are involuntarily 
expelled from time to time by reflex action. 

If the urine dribbles away it is not because the " sphincter " 
(?) of the bladder is paralyzed, but because there is retention 
and overflow — a state demanding the daily use of absolutely 
perfect and carbolized soft catheters. In the earlier stages of the 
affection, the occurrence of increased reflex action in the paretic 
limbs gives rise to a tetanoid state during attempts at standing 
or walking, and too hasty, quasi-involuntary micturition and 
defecation. Later in the disease the paralyzed limbs may be- 



308 LECTURES ON LOCALIZATION. 

come contractured, by reason of secondary changes in the lateral 
columns. 

4 Focal, transverse lesions in the cervical enlargement. Ac- 
cording as the lesion suddenly or gradually affects the whole of 
the cord transversely, or according as it is placed on the lower 
or upper portions of the enlargement, somewhat different symp- 
toms are obtained. They always, however, bear a general re- 
semblance to those in Nos. 2 and 3. 

a. A partial lesion may for a time produce symptoms, numb- 
ness and paresis, in the arms and hands alone, the lower limbs 
being only weak and showing increased reflex. Later, as the 
lesion extends, the legs as well as the arms are paralyzed, and 
the cincture feeling exists high up. 

b. A lesion involving the cord at the level of the eighth 
cervical and first dorsal nerves (see sketch) will give rise to 
paralysis, often with atrophy and loss of faradic reaction in those 
muscles of the upper extremities which are animated by the 
ulnar nerves, i. e., nearly all the small muscles of the hands, and 
some of the flexors of the wrist and fingers. There will be 
sensory symptoms in the same district ; and the cincture feeling, 
if present, will be across the upper part of the chest. The lower 
extremities are paretic or wholly paralyzed, numb, or anaes- 
thetic, according to the completeness of the destruction of the 
spinal tissue. In severe cases nearly all the intercostal muscles 
will also be paralyzed, and thus life will be much more jeopar- 
dized than by lesions placed lower down. The danger is all the 
greater because the expiratory muscles (intercostal, triangularis 
sterni, abdominal muscles) are paralyzed also. 

c. If the lesion be situated in the upper part of the enlarge- 
ment, the motor and sensory symptoms will be apparent in 
nearly the whole of the upper extremities, as well as below them. 
The reflex capacity, the state of bladder and rectum, the faradic 
reactions of muscles remain substantially as in Nos. 2 and 3. 
The cincture feeling is referred to the level of the clavicles, or a 
little lower, across the chest and the arms below the deltoid. The 
difficulty of breathing is even greater than in b. The symptom 
groups produced by lesion No. 4 are often designated by the 
names of cervical paraplegia, or general paralysis. 

In case of lesion in any part of this region (from the level of 
the fourth dorsal to that of the fourth cervical nerves) there may 
be pupillary and facial vaso-motor symptoms. If the lesion be 



LECTURES ON LOCALIZATION. 309 

of such, a nature as to cause irritation of the cilio-spinal centre, 
the symptoms are dilation of the pupils and pallor of the face, 
while if there be a loss of the activity of the cilio-spinal centre, 
the pupils are small and the face and ears flushed and hot. It 
must be added that these vaso-motor and ciliary symptoms are 
not by any means as frequently observed as theory and experi- 
mentation would lead us to expect. 

The same may be said with reference to some peculiarities in 
the action of the heart and variations in the bodily temperature 
which have been observed. In severe traumatic lesions in this 
region, we often find retardation of the pulse, and great eleva- 
tion of the temperature of paralyzed parts. 

Focal, transverse lesions in the upper cervical region. These, 
like No. 4, produce cervical paraplegia, but a much more com- 
plete one. The patient is wholly paralyzed below the head, and 
the entire body may be anaesthetic. Of necessity the phrenic 
nerves are paretic or paralyzed, according to the completeness 
of the injury to the cord, and life is almost immediately termi- 
nated by asphyxia. Cases of this category are nearly always of 
a surgical character ; non-traumatic lesions of this region being 
exceedingly rare. There may be ciliary and facial vaso-motor 
symptoms here as in No. 4, and the bodily temperature and 
pulse-rate are variable. Life is preserved too short a time to 
allow of much study of these symptoms. In slowly developed 
lesions we may have phenomena of irritation, as hiccough, 
dyspnoea, acceleration of the pulse, together with paretic symp- 
toms in the arms and chest, later in the legs. 



Lecture IV. . 

2. NON-SYSTEMATIC OR FOCAL LESIONS OF THE SPINAL CORD CONTINUED ; 
LESIONS INVOLVING ONE LATERAL HALF OF THE SPINAL CORD, IN ITS LOWER 
AND UPPER REGIONS ; DIAGNOSIS OF SPINAL HEMIPLEGIA. — ANATOMY AND 
DISEASES OF THE MEDULLA OBLONGATA. 

Gentlemen :— When a focal lesion, caused by spontaneous dis- 
ease, or by traumatism, involves one lateral half of the spinal 
cord more or less exactly, we observe striking and characteristic 
symptoms in the patient. Some of these are in relation to the 
height of the lesion in the organ as pointed out in the preceding 



310 LECTURES ON LOCALIZATION. 

lecture, but the most important ones are dependent upon the 
fact that one lateral half of the cord is injured in its kinesodic 
and sesthesodic tracts. A reference to Figures 2 and 4 in pre- 
ceding lectures will facilitate the comprehension of what I shall 
have to say upon these lesions. 

According as the lateral focal lesion is placed low down or 
high up in the spinal cord, we denominate the symptom-groups 
as hemi-paraplegia in the first case, spinal hemiplegia in the 
second. 

a. Hemi-paraplegia. A tumor compressing one lateral half of 
the spinal cord in its dorsal (case by Charcot) or lumbar regions, 
a knife-cut, a contusion by a piece of broken vertebra, or a patch 
of hemorrhage or softening, will give rise to this symptom- 
group. Let us suppose the lesion to be situated in the right 
half of the spinal cord. As a result (see Fig. 2) the motor paths 
from the brain and upper spinal cord to the right lower extrem- 
ity are cut off, together with the sensory paths which, crossing 
the median line below the lesion, supply the left lower extremity 
with sensibility. 

In the living human subject we observe motor paralysis, more 
or less complete in the right lower extremity, and the sensibility 
®f this member is preserved or increased. If the lesion be 
t-raumatic and quite complete, hyperesthesia and increased 
temperature are present. In the left lower extremity, on the 
contrary, we find no paralysis, but more or less complete anaes- 
thesia. It is noteworthy that the so-called muscular sense is 
not abolished in that anaesthetic limb. The bladder and rectum 
may be paralyzed. In some cases the distribution of symptoms 
in the two extremities is not as typical and clear as above stated, 
some paresis appearing on the side opposite the lesion, and 
slight loss of sensibility existing on the paralyzed side. This, 
I need hardly say, is owing to the fact that the lesion crosses 
the median line. 

As regards constriction bands, increased reflex, nutrition of 
muscles, and visceral paralysis, regard must be had to the exact 
height of the lesion in the cord, as determined in sections 1, 2, 
3 of the preceding lecture. 

This form of paraplegia can be exactly reproduced in animals. 
It is now nearly thirty years since Brown-Sequard showed to 
the Biological Society of Paris, animals (Guinea-pigs, etc.), in 
which hemi-paraplegia had been produced by cutting one lateral 



LECTURES ON LOCALIZATION. 311 

half of the cord in the dorsal region. The operation is not very 
difficult, and the results are always striking. 

b. Spinal hemiplegia. A lateral focal lesion in the cervical 
enlargement, or above it, will give rise to the following symp- 
toms, more or less exactly distributed. If the right half of the 
organ is the seat of the lesion, we observe that the arm and leg 
on the same side are paralyzed, the intercostals usually escap- 
ing, while on the opposite side there is no paralysis, but more 
or less perfect anaesthesia exists to the median line of the body, 
and as high as the limit of distribution of sensory nerves com- 
ing from the spinal cord just below the lesion. The absolute 
height of the lesion is to be determined as in sections 4 and 5 of 
Lecture III. In these cases we nearly always find, on the same 
side as the injury, contraction of the pupil, redness and increased 
temperature of the face and ear. These symptoms are due to 
paralysis of the vaso-motor and ciliary centers in the spinal 
cord. Often the paralyzed limbs are hotter than the anaesthetic. 

In some cases, owing to incomplete destruction of one lateral 
half of the cord, the arms, thorax, and face alone exhibit symp- 
toms, the legs remaining normal. In other cases various de- 
grees of abnormal reflex action are present in the affected lower 
limbs ; sometimes more on the anaesthetic side. 

We owe a clear conception of these interesting forms of spinal 
paralysis to Brown-Sequard, although some cases of spinal 
hemiplegia had been placed on record before him (Sir Chas. 
Bell, Ollivier, Ore, and others). This distinguished physiolo- 
gist and physician produced spinal hemiplegia and hemi-para- 
plegia in animals from 1849 on, and in 1863-5 published elabo- 
rate memoirs, in which he collected all the cases then known, 
and critically studied their semeiology. In 1868 and 1869 the 
same author published other cases and remarks which have 
placed our knowledge of this subject upon a firm foundation. 
Some doubt exists as to the absolute correctness of Brown- 
Sequard' s law of the course of motor and sensory paths in the 
spinal cord in animals, but in man it would seem, from the study 
of many cases, that the law holds good. 

ANATOMY AND DISEASES OF THE MEDULLA OBLONGATA. • 

Leaving the diseases of the spinal cord to proceed to the con- 
sideration of those of the medulla oblongata, I must again refresh 
your memories upon the physiological anatomy of the parts 



312 LECTURES ON LOCALIZATION. 

concerned ; mentioning only such data as will be of use to us in 
our diagnosis of location of disease. The first, and perhaps the 
most important, point I wish to call your attention to is the 
decussation of the anterior pyramids at the junction of the 
spinal cord and medulla. This decussation is made up of 
bundles of nerve fibers coming from the anterior pyramids of 
the medulla, crossing the median line, and continuing their way 
down the cord in each of its halves, constituting that part of 
the lateral column known as the crossed pyramidal column. 
Another bundle extends downward, without crossing the median 
line, into the inner part of the anterior column, the so-called 
direct pyramidal column (compare Fig. 1, Lecture I.). Accord- 
ing to the books, the uncrossed portion of the pyramidal fascicu- 
lus, the direct pyramidal column, is much smaller and less im- 
portant than the other bundle of fibers which cross the median 
line. 

Of immense importance for the study of localizations in the 
brain, and particularly for the estimation of the symptom hemi- 
plegia, is a knowledge of the exact extent and regularity of this 
decussation, or more strictly speaking, semi-decussation. If we 
are to follow text-books we shall be led to believe that the semi- 
decussation always occurs in about the same proportion on the 
two sides : a view which Brown-Sequard and others admit while 
trying to demonstrate that a lesion of the brain may produce 
paralysis on the same side of the body. Still, in past times a 
few facts had been recorded against the constancy of the pyra- 
midal decussation, but it was not until Flechsig published his 
embryological researches in 1876 that it was known how very 
variable is this decussation. Examining the spinal cord of sixty 
foetuses, this investigator found that the proportion in the size 
of the crossed and direct pyramidal columns varied almost in- 
finitely between the following figures : in one case the direct 
pyramidal column was equal to 90, the crossed column to 10. In 
another case at the other extreme the proportion was to 100 ; 
in other words all the pyramidal fibers had crossed the median 
line. There was no case in which there was absolutely no de- 
cussation, but Flechsig correctly remarks that there is no reason 
why such a specimen should not be met with. The majority of 
the foetuses had an ordinary semi-decussation, the crossed 
bundle predominating over the direct. The above variations 
in the pyramidal decussation are diagrammatically represented 



LECTURES ON LOCALIZATION. 



313 



in Fig. 5. Besides, Flechsig determined that there were other 
irregularities in the proportionate size of the four columns (two 
crossed pyramidal columns, two direct) which result from the 




Diagram explicative of pyramidal decussation : p v, pons Varolii ; m o, medulla oblongata ; o } 
olivary body ; a p, anterior pyramid ; d, decussation ; s c, spinal cord. The direct and crossed 
bundles vary very much in size, as shown in the following ratios of crossed and direct : 100 : 
0, 92 : 8, 84 : 16, 70 : 30, 52 : 48, 35 : 65, 10 : 90.— {Flechsig.) 

breaking up of the pyramids, but this is not essential to our 
present study. 

The practical bearing of this discovery is very great, for it will 
be readily understood that in the exceptional cases in which the 
pyramidal decussation is nearly wanting, an unilateral lesion of 
the medulla, pons, or brain must give rise to symptoms of para- 
lysis on the same side as the lesion. 

Again, in those few cases in which the semi-decussation is 
nearly equal, an unilateral lesion above the spinal cord will pro- 
duce weakness on both sides of the body. Lastly, in the im- 
mense majority of cases, those in which most of the pyramidal 
fibers cross the median line, we obtain the classical crossed 
hemiplegia. It is ignorance of these researches of Flechsig 
which makes that distinguished physiologist, Dr. Brown- 



314 LECTURES ON LOCALIZATION. 

Sequard, invert the reasoning and draw chaotic and iconoclastic 
conclusions respecting the mode of production of hemiplegia 
(and other symptoms of brain disease). Starting with the gen- 
erally received doctrine (never proven in a scientific way) that 
the pyramidal decussation is invariable and nearly total, and 
finding scattered in medical literature more than three hundred 
cases in which paralytic symptoms appeared on the same site as 
the lesion, he concludes that we are all wrong in considering 
hemiplegia to be due to destruction of or pressure upon motor 
tracts in the brain and basis cerebri. 

Bearing in mind Flechsig's demonstration, the erroneous logic 
of the above is evident. Besides, these exceptional cases, so 
laboriously collated, should be looked at in another way. Most 
of them are old cases, i.e., cases reported before modern cerebral 
anatomy was understood ; many of them are related by men 
utterly or relatively unknown. Furthermore, any one who has 
worked much in the post-mortem room will appreciate how 
easily right is wrongly written, when left is meant, as a brain is 
turned over and around for examination. Consequently, we 
might claim the right to reject as worthless many of these three 
hundred or more cases. Suppose, however, that they are ac- 
cepted as bona fide examples of palsy on the same side as an 
encephalic lesion, and that we compare them with the thousands 
of cases of classical hemiplegia on the side opposite the cerebral 
lesion, do we obtain a proportion greater than that observed in 
Flechsig's series of foetuses, one to sixty ? I think not. 

I have thus digressed from proper medulla diseases in order 
to treat the subject of pyramidal decussation fully, i. e., anatom- 
ically and clinically, in one lecture. Having done this will save 
much repetition in treating of lesions above this point. 

The pyramids whose decussation we have studied are the 
direct motor tracts which connect the cerebral cortex with the 
spinal cord. They are externally visible on the anterior 
(inferior) surface of the medulla, can be traced in the pons and 
crura, and thence into the internal capsule in the white centre 
of the hemispheres, to those parts of the cerebral cortex which 
are now considered as in some way motor. In subsequent lec- 
tures I shall describe this great motor tract more fully, and give 
you the reasons for believing it to be continuous from the cortex 
to the end of the spinal cord. The remainder of the kinesodic 
system of the medulla embraces longitudinal bundles of fibres 



LECTURES ON LOCALIZATION. 315 

which lie between the two olivary bodies (supposed to be in 
connection with the ganglia at the base of the cerebrum and the 
various nuclei of motor nerves in the floor of the fourth 
ventricle. These nuclei, or groups of motor (and trophic ?) 
cells, represent the anterior horn cells of the spinal cord, 
strangely thrown backward and toward the median line. They 
differ from the cell-groups of the anterior horns also in being 
more differentiated in relation to the nerves which arise from 
them. Reckoning from below upward, we find the nuclei of 
origin of the spinal accessory (11th), hypoglossal (12th), facial 
(7th), and abducens (6th) nerves. The last two lie on the con- 
fines of the medulla and pons. These nerves and their nuclei 
must, I think, be looked upon as active in three ways : 1, by 
their own (trophic?) neurility ; 2, by reflex action set up through 
the adjacent and correlated sensory nerves ; 3, by impulses 
coming from supra-bulbar jmrts, great basal ganglia, cortex of 
the brain. This last connection is undoubtedly a crossed one, 
i. c, the fibres or paths which transmit the motor impulse down 
to these nuclei cross the median line at some unknown distance 
above them. There is therefore another motor decussation 
besides the great one described above. 

The sesthesodic system of the medulla oblongata occupies its 
lateral portions chiefly, and a part of the gray matter under the 
floor of the fourth ventricle, outside of the series of motor nuclei. 
In this gray matter we find, from below upward, the nuclei of 
origin of pneumogastric (10th), glosso-pharyngeal (9th), and 
acoustic (8th) nerves. All through the lateral region of the 
medulla posterior to the olivary bodies lies the great ascend- 
ing root of the trigeminus (5th) nerve, which meets with groups 
of cells throughout this region down to the uppermost parts of 
the spinal cord. 

These various nuclei and nerves, kinesodic and sesthesodic, 
make up arcs for reflex actions of the most important kind, as 
breathing, swallowing, and (with gray matter in the pons) the 
state of vascular tonus. The respiratory centre (so-called) is in 
the nuclei of the pneumogastrics, the vaso-motor centre lies near 
the median line at the junction of the medulla and pons, and 
there are various subordinate foci or centres for important mor- 
bid actions, as the diabetic centres, the albuminuric centre, etc. 
Besides, the hypoglossal nuclei and nerves preside over the 
movements of the chief organ of speech. 



316 LECTURES ON LOCALIZATION. 

I should add that the medulla oblongata has intimate though 
ill-understood connections with the cerebellum, by means of 
the restiform and olivary bodies. 

As regards the localization of disease in the medulla, I shall 
have but little to say, for the reason that, in accordance with 
the terms of the course, I am bound to speak of only well- 
determined clinical forms whose lesions can be diagnosticated. 
Consequently, I will say nothing of systematic lesions in the 
bulbar sesthesodic system, nothing of bulbar lesions in diabetes 
mellitus, almost nothing of focal lesions of the organ. 

a. Systematic lesions of the kinesodic tract are represented 
by only one typical symptom-group, viz. : the so-called labio- 
glosso-laryngeal paralysis, or bulbar paralysis. The lesion in 
this disease consist of granular degeneration of the ganglion 
cells of the nuclei of origin of the hypoglossus, spinal accessory, 
and of part of the facial nerves. The alteration is very like 
that present in progressive muscular atrophy (systematic lesions 
of the spinal cord, No. 5, Lecture III.), a molecular death, by 
degeneration, of ganglion cells. 

The symptoms of typical labio-glosso-laryngeal paralysis are 
strictly motor, and consist in fibrillary contractions in and 
atrophic paralysis of the orbicularis oris, muscles of the tongue 
and throat, and some muscles of the larynx. Labial sounds are 
interfered with, saliva dribbles from the mouth, forcible blowing 
or whistling becomes impossible, the tongue plays heavily in 
the mouth as shown by thickness of speech and by difficult 
mastication, the voice becomes nasal through palatal paresis, 
and hoarseness, almost aphonia, is produced by palsy of the 
laryngeal muscles. At the same time, in extreme cases, the 
lower facial muscles become inert, the lower jaw hangs 
down, and an abundance of tenacious saliva runs from the 
patient's mouth ; speech is quite unintelligible, and swallow- 
ing performed with extreme difficulty. At the close of life, if 
that be not cut short by the lodgment of food in the larynx, 
there are symptoms of injury to the pneumogastric nucleus, such 
as exceedingly rapid pulse and sudden stoppage of respiration. 

In certain non-typical cases the lips, tongue and throat are 
affected in very various degrees ; in others the pneumogastrics 
suffer early ; and in others still the symptoms of progressive 
muscular atrophy, or of amyotrophic lateral sclerosis (Lecture 
II.) set in simultaneously or subsequently. I am disposed to 



LECTURES ON LOCALIZATION. 317 

believe that we may have many forms of " bulbar paralysis," 
and consequently would use the term as a generic one to embrace 
certain varieties, only one of which is now well known. 

[It will be asked why I do not speak at length of descending 
degeneration through the medulla. This lesion is the continu- 
ation downward of a degenerative change in the motor tract 
beginning in the cerebral cortex, the internal capsule, the nuclei 
of the corpus striatum, or in the basis cerebri. 

It usually affects only one anterior pyramid, and is continued 
downward into the cord, in its direct and crossed pyramidal, 
columns. No symptoms indicate this alteration in the medulla, 
and we infer its existence from the diagnosis of descending 
degeneration in the spinal cord (Section 3, Lecture II.). I do 
not formally treat of this systematic bulbar lesion for the reason 
that it has no semeiology.] 

b. With respect to focal lesions. A lesion involving one 
lateral half of the medulla will produce, first, symptoms of 
injury to the kinesodic and sesthesodic systems in that half of 
the medulla, the symptoms being on the same side as the lesion ; 
and second, hemiplegia of motion (and sensation, if the injury 
be deep enough) in the opposite side of the body. Again, a 
superficial focal lesion involving the anterior (inferior) face of 
the medulla may produce symptoms closely resembling those of 
bulbar paralysis of the type labio-glosso-laryngeal paralysis ; 
and perhaps the only way of reaching a correct diagnosis is by 
determining the presence of the degeneration-reaction in the 
paralyzed facial and lingual muscles, and by demonstrating 
weakness or positive palsy of the extremities. 

An exceedingly atypical form of bulbar paralysis is the one 
caused by ischsemia of the. medulla, owing to arrest of circulation 
in the vertebral and anterior spinal arteries. The symp- 
toms are mixed motor and sensory (deglutition, and articulation 
impaired, breathing of the Cheyne-Stokes type, rapid pulse, 
tottering gait or marked general paralysis) and death rapidly 
ensues. 



318 LECTURES ON LOCALIZATION. 



Lectuee Y. 

SUMMARY : — LESIONS OF THE BASIS CEREBRI ; PHYSIOLOGICAL ANATOMY OP 
THE PARTS INVOLVED. 1. LESIONS OF THE PONS VAROLII. 2. LESIONS OF 
THE CRURA CEREBRI. 3. LESIONS OF THE BASAL PARTS FORWARD OF THE 
CRURA ; gpMIOPIA AND NEURO-RETINITIS. 

Gentlemen : — Leaving the region of the medulla, we are 
brought to those numerous and important parts which constitute 
the encephalon. I purpose considering in some detail, in this 
and subsequent lectures, the localization of disease in the chief 
subdivisions of this mass, but in this lecture I can only enun- 
ciate some general pathological propositions relative to the 
encephalon as a whole, and study the lesions of one of its parts. 

For our purpose I make the following subdivision of the 
encephalon — a semi-physiological classification : 

1. The basis cerebri, including all the parts which lie upon 
the base of the skull, but more especially the pons Varolii, 
crura cerebri, their attached nerves, and the optic and olfactory 
apparatuses. 

2. The great basal ganglia, i.e., the thalamus opticus, nucleus 
caudatus, nucleus lenticularis, and the corpus quadrigeminum. 

3. The white substance of the hemispheres, especially the 
internal capsule. 

4. The cortex cerebri. 

5. The cerebellum. 

The general pathological propositions relative to these parts 
are as follows : 

1. Lesions of the basis cerebri, especially if involving the 
pons and crura, give rise to the following symptoms : paralysis 
(often of crossed variety), anaesthesia in the face and limbs, 
impairment of equilibrium, changes within the eyes ; no psychi- 
cal symptoms. 

2. Lesions of the great basal ganglia probably produce no 
symptoms unless by encroaching upon the internal capsule 
which passes near them. An exception may be the nucleus 
caudatus. 

3. Lesions of the white centre of the hemispheres produce no 
symptoms when they do not involve the parts composing the 
internal capsule ; if the anterior portion of this* capsule be 
injured, we observe paralysis, if its posterior part, anaesthesia. 



LECTURES ON LOCALIZATION. 319 

4. Lesions of the cortex cerebri produce, when located an- 
teriorly, psychical symptoms ; when located in the median 
regions, paralysis of an imperfect kind, and when situated pos- 
teriorly, no symptoms at all (sensory symptoms in animals). 

5. Lesions of the cerebellum produce no symptoms except by 
involving adjacent parts containing important motor and sensory 
tracts ; thus giving rise to irregular paralyses, changes in the 
optic apparatus, symptoms of irritation of the vagus nerve, etc. 

6. Lesions in one lateral half of any part of the encephalon 
produce motor and sensory symptoms in the side of the body 
opposite to the lesion. When the lesion is in one-half of the 
basis cerebri some symptoms (direct symptoms) are found in the 
side of the face and head corresponding to the lesion, others in 
the opposite half of the body (crossed paralysis). 

7. Lesions in the median line cause symptoms to appear in 
both sides of the body. 

8. Any intracranial lesion which acts in such a way as to 
increase the intracranial pressure may produce (in addition to 
other symptoms) the condition known as choked disk, or neuro- 
retinitis. 

"With these preliminary general statements, I pass to the study 
of the first of the subdivisions — the basis cerebri : 

PHYSIOLOGICAL ANATOMY. 

To be very logical, the medulla oblongata, pons, and crura 
should be grouped together under this denomination, but for 
clinical purposes I leave the medulla with the spinal cord, and 
add to the basis cerebri the parts which lie in front of the crura, 
viz., the optic tracts and nerves, and the olfactory apparatus. 

As heretofore, I assume that you are familiar with the descrip- 
tive anatomy of the parts ; and what I wish you particularly to 
understand is the arrangement of sensory and motor tracts, of 
nerves, and of ganglia in the basis cerebri. 

The projecting mass we call the pons is largely made up of 
numerous transverse nerve-fibers which connect it with the two 
halves of the cerebellum, and which are not, under our present 
knowledge, of special physiological or pathological importance. 
In the anterior (inferior) half of the pons, lying under those 
transverse fibers and, partly separated into bundles by them, we 
find the great motor or peduncular tract, the continuation up- 
ward of the anterior pyramids and of the central motor fasciculi 



320 LECTTTBES ON LOCALIZATION. 

of the medulla. This tract is easily seen with the naked eye, 
broken up into a number of smaller fasciculi by transverse fibres, 
and it can be traced upward a long distance. In the posterior 
(superior) region of the pons, under the flcor of the fourth ven- 
tricle, near the median line, there is a lengthened mass of motor 
gray matter, whence arise the original fibres of the sixth, seventh, 
and motor root of the trigeminus nerves. Laterally, in the pos- 
terior part of the pons, are sensory tracts, some directly continu- 
ous with the brain above, others more particularly in relation 
with the sensory root of the trigeminus, which radiates to an 
immense extent up and down in the basis cerebri and below it. 

In the crura cerebri we find substantially the same parts not 
covered over by transverse fibres. The anterior portion of the 
crura consists of the great motor or peduncular tract just 
issued above from the white matter and basal ganglia of the 
cerebrum. Posteriorly are sensory tracts and masses of gray 
matter in intimate relation with the thalamus opticus and corpus 
quadrigeminum. The final (upper) extremity of the elongated 
mass of gray matter giving rise to motor nerves is found here, 
posteriorly, just beneath the aqueduct of Sylvius, in the shape 
of the common nucleus of the third and fourth nerves. Let us 
finally bear in mind that the sixth, seventh, and fifth nerves are 
intimately connected with the pons Varolii ; the third and fourth 
nerves, and the optic tracts are associated with the crura. 

The posterior portions of the crura and pons constitute the 
greater part of what Meynert designates the tegmentum cruris cere- 
bri, while their anterior parts contribute to form his basis cruris 
cerebri. 

All these parts lie in the middle fossae of the cranium, the 
chiasm of the optic nerve occupying their forward extremity. 
In the anterior fossae we find only the olfactory commissures and 
ganglia, together with the under surface of the frontal lobes of 
the cerebrum. 

As regards the physiology of these parts, the mesencephalon 
of some authors, we may sum it up as follows : 

The anterior part of the crura, pons (apart from the super- 
ficial transverse fibres), and medulla oblongata, contains the 
chief motor tract connecting the superior centres with the spinal 
cord. This motor tract is made up of nerve fibres, which convey 
excitations chiefly in a centrifugal direction ; many of them, de- 
rived from the motor regions of the cortex, constitute the anterior 



LECTURES ON LOCALIZATION. 321 

portion of the internal capsule, and then enter the crura, tra- 
verse the pons, go to make up the anterior pyramids of the 
medulla, partially and irregularly decussate at the pyramidal 
decussation, and finally are found in the postero-lateral and an- 
terior columns of the spinal cord. This most important bundle 
of nerves may be designated as the direct cerebral motor tract. 
Another portion of the anterior region of the mesencephalon is 
likewise motor in function, and is made up of bundles of fibres 
derived from the nucleus caudatus and nucleus lenticularis. 
These bundles can be traced downward into the middle regions 
of the medulla, but their connection with the spinal cord is yet 
uncertain. The posterior region of the pons and crura, com- 
posed largely of gray matter, is partly sensory and partly motor. 
It is motor only in so far as it includes the nuclei of origin of 
the upper cranial nerves, the seventh, sixth, motor root of fifth, 
the fourth and third. You will remember that the nuclei of 
these nerves are all to be found near the median line, underneath 
the floor of the fourth ventricle or its continuation, the aqueduct 
of Sylvius. The sensory parts of the mesencephalon embrace 
the regions lying external to these nerves, giving origin to the 
eighth and fifth pairs of nerves ; the latter presenting an enor- 
mous expansion in its origin ; its upper roots extending as high 
as the region of the corpus quadrigeminum, the lowest probably 
as far down as the upper part of the spinal cord. 

The posterior regions of the mesencephalon, the tegmentum 
cruris, are the seat of the reflex actions of the most important 
character, and they probably serve also for the elaboration, if 
not perception, of sensory impressions from the periphery. At 
the upper part of the medulla and the lower part of the pons in 
this region is a mass of gray matter which controls the vaso- 
motor phenomena throughout the body. It is highly probable 
that some severe convulsive manifestations, such as epileptic 
and tetanic seizures, are due to morbid processes in the posterior 
part of the pons and crura. 

Finally, with respect to the physiology of the optic apparatus 

lying at the base of the brain, I will only say that I am disposed 

to accept the doctrine of semi-decussation of the optic tracts in 

the chiasm, and shall use this hypothesis in explanation of 

symptoms. 

21 



322 LECTURES ON LOCALIZATION. 

SYMPTOMS OF LESIONS OF THE BASIS CEBEBBI. 

Before taking up systematically the study of the semeiology of 
basal lesions, allow me to fully discuss one of the most frequent 
symptoms of all these lesions, viz., crossed paralysis. I wish to 
study crossed paralysis in general, previous to speaking of it 
under each heading of the remainder of this lecture, partly to 
impress you with its importance, and partly to avoid future 
digressions and repetitions. By crossed paralysis (paralysie 
alterne of the French) is meant a form of paralysis in which the 
symptoms immediately caused by a basal lesion are on one side 
of the face or head and on the same side as the lesion, while the 
bodily symptoms are on the opposite side of the median line, 
viz., on the side opposite the lesion. As thus enunciated, in 
principle, it is at once apparent that the phenomena of crossed 
paralysis may, according to the seat of a lesion at the base of 
the brain, involve, on the one hand, any one of the cranial 
nerves, and on the other the limbs of the opposite side. This 
conception is verified by clinical and post-mortem experience, 
cases of crossed paralysis of every possible variety being on 
record. The most striking and best known, however, are those 
presenting what I may be allowe'd to term the third nerve and 
body type, the trigeminus and body type, and the seventh nerve 
and body type. It is to the late Prof. Romberg, of Berlin, that 
we owe the exact definition and conception of the principle of 
crossed paralysis, while Prof. Gubler, of Paris, first made a 
thorough study of the seventh nerve and body type. 

1. LESIONS OF THE PONS VAROLII. 

Diffused lesions of the pons produce, when fully developed, 
partial anaesthesia and paresis on both sides of the face, gener- 
alized paralysis below the neck, with or without anaesthesia, the 
latter symptom appearing only if the deeper, posterior, portions 
of the organ are involved. "We also observe inability to main- 
tain equilibrium, without ataxia, sometimes convulsions, or con- 
tracted pupils, or neuro-retinitis. If the lesion advance forward 
beyond the pons, new symptoms such as will be described 
further on are superadded. 

Localized lesions of the pons may occupy on either side of 
the median line one of four locations. 

a. In the anterior portions of the pons forward of an imagin- 



LECTURES ON LOCALIZATION, 323 

ary transverse line passing through the origin of the trigemini. 
As shown by Gubler, this lesion does not produce crossed 
paralysis of the seventh nerve and body type, but both the face 
and body are paralyzed on the same side, i.e., on the side 
opposite the lesion, just as in cerebral lesions strictly speaking. 
A point for differential diagnosis is that when the cerebrum is 
injured, there is almost invariably conjugate deviation of the 
head and eyes toward the affected hemisphere ; in pons lesions 
nothing of the kind occurs. 

b. A lesion placed so as to injure the anterior (inferior) region 
of the pons on one side, back of the imaginary line above men- 
tioned, will cause typical crossed paralysis, i.e., the facial nerve 
will be paralyzed on the same side as the lesion, and the ex- 
tremities on the opposite side. For example, if the right face 
and the left arm and leg be palsied in a patient, we recognize 
crossed paralysis of the seventh nerve and body type, and may 
diagnosticate with positiveness a lesion placed as above de- 
scribed. There is, perhaps, no more positive example of con- 
stant relation of lesion to symptoms in the whole of nervous 
pathology. 

In a and b, if the trunk of the trigeminus be involved in the 
disease, the face will be more or less anaesthetic and neuralgic 
on the same side as the facial palsy and the lesion. From a 
study of cases of these two kinds, Gubler drew the anatomical 
conclusion that the paths which connect the cerebrum with the 
nuclei of the seventh nerve decussate at about the middle of 
the pons, i.e., some distance above the nuclei of these nerves. 
A useful diagram for studying the principle of crossed paralysis, 
and of this type in particular, you will find in Dr. Hammond's 
Treatise on Diseases of the Nervous System, ed. 1876, p. 99. 

c. Lesions occupying the posterior region of the pons above 
its middle. Besides paralysis of the face and body on the side 
opposite the lesion, we are likely to have anaesthesia of the 
paralyzed parts, even amounting to hemi-anaesthesia (without 
involvement of the special senses). Other symptoms often pro- 
duced are epileptic convulsions, impairment of sight from neuro- 
retinitis, and various forms of paralysis of ocular muscles. 

d. Lesions in the posterior part of the pons, below the imag- 
inary transverse line through its equator, may likewise, if exten- 
sive, without crossing the median line, cause he mi-anaesthesia 
of common sensory nerves, but will also produce crossed palsy, 



324 LECTURES ON LOCALIZATION. 

of face on same side as the lesion, of the body on the opposite 
side, As in c, we may have neuro -retinitis, epileptic seizures, 
with, besides, palsy of the sixth nerve, and bulbar symptoms if 
the lesion involve the medulla. 

e. A lesion situated very laterally in the pons, or so placed as 
to irritate the lateral peduncles of the cerebellum, will (as shown 
by a number of cases) give rise to rotatory movements of the 
patient around the long axis of his body toward the side of the 
lesion. Of course this symptom appears with others, which are 
more or less in accord with the above symptom-groups. 

2. LESIONS OP THE CRURA CEREBRI. 

a. Lesions of the crus proper on one side of the median line. 
The symptoms of such a lesion are exceedingly definite, and 
might even be designated pathognomonic. The third nerve, its 
trunk or origin, is involved in the disease or compressed, as well 
as the great motor tract which, lower down, is to decussate. 
Consequently we observe a crossed paralysis of the third nerve 
and body type ; L e., if the right motor oculi, the left lower face 
and the left extremities be paralyzed in a patient, we may feel 
sure that he has a lesion under or in the right crus cerebri. 
Prof. Rosenthal, of Vienna, states that in such cases the electro- 
muscular contractility (to faradism) is reduced in the paralyzed 
limbs, contrary to what obtains in hemispheric lesions. You 
will remember that the optic tract curves around the crus on 
either side, and it at times happens that symptoms characteris- 
tic of injury to one optic tract present themselves. These symp- 
toms will be considered later. 

b. Lesions deeply placed in the crus, on one side of the me- 
dian line. In addition to the above described crossed paralysis, 
we shall probably observe para] y sis of the lower part of the face 
on the side opposite the lesion and hemi-ansesthesia of common 
sensation only on the side opposite the lesion. There may be 
convulsions, choreiform spasm, hemiopia, or neuro-retinitis. 

c. Lesions placed in the median line, or involving both crura 
more or less. The symptoms will be, in case of lesion situated 
anteriorly (inferiorly), wholly motor, viz. : paralysis of both third 
nerves ; the lower half of both sides of the face and of both sides 
of the body below the neck. In case of lesion involving the 
tegmentum cruris, marked disorders of sensibility, neuro-reti- 
nitis, and convulsions will occur. 






LECTURES ON LOCALIZATION. ' 325 

Extension of the disease backward to the pons will be char- 
acterized by symptoms (detailed in first paragraph) referable to 
the trigeminus and seventh nerves. 

It has been stated that the bladder is paralyzed in severe 
lesions of the crura, but this lacks confirmation. 

It might not be ill to add that patients having lesions in the 
locations defined above, do not present, strictly speaking, cere- 
bral symptoms. They preserve their intellect, are not aphasic, 
and the special senses (except the sense of sight) are not in- 
volved. 

3. LESIONS SITUATED AT THE BASE OF THE BRAIN ANTERIORLY TO THE 

CRURA. 

These are rare, but give rise, when considerable, to notewor- 
thy symptoms. 

a. Lesions involving one of the optic tracts posterior to the 
chiasm. A small lesion in this location will produce hemiopia, 
a symptom of such importance and scientific interest as to re- 
quire special mention. If the lesion extend, it may involve the 
chiasm of the optic nerves, or the tract of the opposite side, or 
the crura cerebri, thus either destroying the special symptom, 
hemiopia, or adding to it the signs of crossed paralysis of third 
nerve and body type. 

By hemiopia is meant a condition of the organs of vision, 
such that only one-half (vertically divided) of objects are seen 
by the patient. In other words, the fields of vision of the two 
eyes are darkened in one of their halves. Usually the vertical 
line of division between the lighted and darkened half-fields is 
exactly in the centre of vision. The hemiopia affects the two 
eyes always, and is distributed differently in each eye under the 
determining influence of the exact location of lesions about the 
optic tracts and chiasm. The immediate cause of hemiopia is 
interruption in the centripetal conducting power of certain bun- 
dles of nerve-fibres in the optic nerves and tracts ; hence it has 
been found necessary to frame a theory of the course of fibres in 
the optic apparatus. The hypothesis of TVollaston, that of semi- 
decussation, is the one which is generally adopted to-day, and 
I append a diagram illustrating it, and the positions of lesions 
producing the varieties of hemiopia. A satisfactory anatomical 
demonstration of the truth of the theory of semi-decussation 
has not yet been given, and some few facts and authorities are 



326 LECTURES ON LOCALIZATION. 

opposed to it, but I think that I can assure you that in the present 
state of science it is the one which best serves the purposes of 
the physiologist and the clinical observer. 

According to this hypothesis nerve-fibres derived from the 
deep origins of one (the left) optic tract, combine to form that 
bundle, and extend undivided as far as the chiasm. As shown 
in Fig. 6, at the chiasm some of the fibres of the tract (the ex-; 
ternal group possibly) pass directly into the external portions 
of the left optic nerve, and are distributed to the external (tem- 
poral) half of the left retina. The remaining nerve-fibres of the 
left optic tract cross the median line in the middle of the chiasm, 
decussating with the similar fibres derived from the right tract, 
then enter the right optic nerve, and are distributed to the 
inner (nasal) half of the right eye. Thus it is seen that the nasal 
half of the right eye and the temporal half of the left eye are 
anatomically and physiologically homologous. 

The same explanation applies to the course of fibres which 
form the right optic tract. Besides these main bundles of fibres, 
a few filaments are supposed to connect the two retinae, passing 
through the optic nerves and the anterior border of the chiasm 
without decussation, while others connect the two sets of tuber- 
cula quadrigemina by way of the optic tracts and the posterior 
border of the chiasm. These commissural fibres may, however, 
be left out of consideration in the study of hemiopia. 

If now we bear in mind this distribution of fibres in the optic 
apparatus, we can, by the aid of Fig. 6, demonstrate the mechan- 
ism of each of the four forms of hemiopia, viz.: right and left 
lateral hemiopia (shaded parts A and b), bi-temporal and nasal 
hemiopia. 

Lateral hemiopia, i. e., that form of hemiopia in which the 
homologous parts of the two eyes (temporal half of the left 
retina and the nasal half of the right) lose their function, is in- 
variably produced by a lesion destroying one optic tract — the 
left in the diagram. Vice versa, destruction of any part of the 
right optic tract would cause blindness in the temporal half of 
the right retina and in the nasal half of the left. Inasmuch as 
all visual rays cross in the eyes, owing to refraction in the lens, 
the hemiopia, i. e., the obscuration of the half -fields of vision, 
is on the opposite side from the blind-half retinae. For ex- 
ample, in the first instance described above and illustrated in 
the diagram, the hemiopia is of the form designated right lateral 



LECTURES ON LOCALIZATION. 



327 



(or homonymous) hemiopia, and is produced by a lesion involv- 
ing the left tractus opticus. 

Binocular temporal hemiopia can be caused only by a lesion 
placed (as 1 in Fig. 6) in front of the chiasm, cutting off the 
fibres which supply the two nasal fields. 




ic 



/ 1 
! i 
ic 



Fig. 6. 



Diagram explicative of hemiopia. The shaded intra- and extra-ocular parts, a and b, indi- 
cate the obscuration in right lateral (or homonymous) hemiopia, as caused by lesion 3, so placed 
as to destroy one optic tract. In that tract are two sets of nerve fibres, one represented by 
a dotted line supplying the nasal half of right retina, the other fibres by a broken line supply- 
ing the outer or temporal half of the left eye. As visual lines cross in the eye the obscuration 
of the half-fields is the opposite. Lesion No. 1, anterior to chiasm, produces blindness of 
inner half of each retina, and consequently bi-temporal hemiopia. Lesions No. 2, pressing upon 
the sides of the chiasm, injure fibres supplying the temporal half of each retina, and cause bi- 
uasal hemiopia. c., corpus quadrigeminum, in which Prof. Charcot believes a second partial 
decussation takes place, i.e. Internal capsule containing, on Charcot's hypothesis, all the fibres 
coming from the eye of the opposite side. 4. Lesion of internal capsule injuring all the, 
fibres connected with the right retina, and causing amblyopia of the right eye. 



328 LECTURES ON LOCALIZATION. 

Binocular nasal hemiopia is produced by a double lesion com- 
pressing or destroying the outer parts of the chiasm (2 in Fig. 6), 
which are imbedded fibres supplying the temporal halves of both 
retina. Prof. Knapp, of New York, has placed a remarkable 
case of this kind on record, in which the lesion consisted of 
thickened and enlarged internal carotid arteries. I need 
hardly add that lesions involving one optic nerve in front of the 
chiasm cannot give rise to hemiopia ; they produce monocular 
loss of vision. 

It should not be forgotten that lesions lying in front of the 
crura and behind the chiasm may press upon the motor nerves 
of the eye as they traverse the middle fossse of the cranium on 
their way to the sphenoidal fissure, thus producing a variety of 
paralytic symptoms about one or both eyes. 

b. Lesions in the anterior cranial fossa, anterior to the chiasma. 
When unilateral, such a lesion involves the olfactory tract and 
ganglion, thereby producing anosmia, or loss of smell, on the 
same side as the lesion, with or without subjective odors. 

If the lesion be large, it may act upon the nucleus caudatus 
or other motor parts of the encephalon, and cause common 
hemiplegia (face and limbs) on the opposite side. Thus we may 
have a last form of crossed paralysis, of the olfactory nerve and 
body type. With a lesion involving both sides of the median 
line, complete double anosmia, with or without generalized 
paresis of the extremities, would be met with. 

There is one more symptom common to all lesions of the 
basis cerebri, but produced also at times by any intracranial 
disease which causes pressure. I mean neuro-retinitis or choked 
disks. This is always (?) bilateral, though it may be more 
marked in one eye, and is esteemed one of the most important 
signs of gross encephalic disease, especially of tumors. In 
neuro-retinitis, ophthalmoscopic examination shows that the 
optic nerves are swollen, and they may project considerably 
(measurably) above the level of the surrounding retina ; the 
margin of the disk is obscured or wholly lost, and no line of 
demarcation can be made out between the nerve and the retina. 
The blood-vessels present striking anomalies, the arteries being 
relatively small, the veins positively enlarged and tortuous ; 
there are often small hemorrhages in the retina, round about 
the disk. Strange to say, very good sight may coexist with this 
lesion. This condition of choked disks may last a number of 



LECTURES ON LOCALIZATION. 329 

weeks (much longer in cases of tumor of the brain), and then 
subside, giving place to the appearances of atrophy of the optic 
nerves, viz., an unnatural whiteness or bluish whiteness of the 
disk, smallness of the retinal vessels, and unusual sharpness of 
the outline of the disk, with impaired vision. 



Lectuke VI. 

i 

SUMMARY : — LESIONS OF THE GREAT GANGLIA AT THE BASE OF THE BRAIN, 

AND OF THE WHITE SUBSTANCE OF THE HEMISPHERES. SKETCH OF THE 

PHYSIOLOGICAL ANATOMY OF THESE PARTS: LESIONS OF THE GREAT BASAL 
GANGLIA OF THE INTERNAL CAPSULE, AND OF THE REMAINDER OF THE 
WHITE SUBSTANCE. — LESION OF TOE CEREBELLUM. 

Gentlemen : — The great ganglia at the base of the brain are 
from before backward, the nucleus caudatus and the nucleus 
lenticularis of the corpus striatum (the intra- and extra-ventricu- 
lar portions of the corpus striatum, according to English and 
American books), the thalamus opticus, and the corpus quadri- 
geminum (or tubercula quadrigemina). These masses of gray 
matter are of course double, i.e., symmetrically arranged on 
either side of the median line. Their relations to adjacent por- 
tions of the brain are of great importance to us, and worthy of a 
somewhat detailed study. 

In very general terms, it may be said that all of these bodies 
have at least a duplex connection, one superior, with the cortex 
of the brain, the other inferior, with the various parts which 
make up the mesencephalon. More particularly, the nucleus 
caudatus (intra-ventricular nucleus of the corpus striatum) sends 
bundles of fibres downward into the crura, and the same is true 
of the externally-placed nucleus lenticularis. So we say that 
both parts of the corpus striatum are intimately connected with 
the basis cruris cerebri. 

On the other hand, the thalamus and corpus quadrigeminum 
are intimately united with the nucleus of the tegmentum, and 
send bundles of fibres into and through it, in the posterior or 
sensory system of the mesencephalon. Physiologically, we may 
look upon the basis cruris and its superadded ganglia as motor 
in function, and upon the tegmentum cruris as sensory and as 
the seat of performance of important and complex reflexes. 

As regards the other connections of these bodies, they are 



330 



LECTURES ON LOCALIZATION. 



probably connected with their homologues across the median 
line, and superiorly with various parts of the cortex. There 
would seem to be, judging from a series of cases of cerebral 
atrophy, a bundle of nerve fibres connecting the nucleus cau- 
datus of one side with the opposite half of the cerebellum by 
way of the processus cerebelli ad cerebrum. At any rate, great 
atrophy of the right hemisphere (for example) and corpus stri- 
atum is usually accompanied by atrophy of the left hemisphere 
of the cerebellum. I need hardly remind you of the intimate 
union between the optic tracts and the corpus quadrigeminum 
and the external portion of the thalamus. 

The white centre of the hemispheres is made up of many 
separable fasciculi, the physiology of many of which is as yet 
obscure. In the first place, we can demonstrate in it commis- 
sural bundles running in various directions : transversely, con- 
necting various portions of the cortex of both hemispheres by 
way of the corpus callosum and the so-called commissures ; 
others extend longitudinally in one hemisphere, connecting the 




Fig. 7. 
Diagram of course of sensory and motor tracts in the mesencephalon and hemispheres, s, sensory 
tract in posterior region of mesencephalon, extending to o and t, occipital and temporal lobes 
of hemispheres ; m, motor tract in basis cruris, extending to p and v, parietal and (part of) 
frontal lobes of hemispheres ; c q, corpus quadrigeminum ; o T. optic thalamus ; N L, nucleus 
lenticularis ; N c, nucleus caudatus. 

convolutions of one lobe with those of another ; yet others simply 
bind together adjacent convolutions. Secondly, there are heavy 
masses of fibres extending from the basal ganglia to the convolu- 
tions of the hemispheres, constituting a great part of what is 
known as the corona radiata. Thirdly, and most important in 
pathology to-day, is a bundle of white substance in each hemi- 



LECTURES ON LOCALIZATION. 



331 



sphere, which directly unites the cortex of the brain with the 
crura, pons, and spinal cord — the so-called internal capsule. 
This fasciculus appears (upon anatomical and physiological evi- 
dence) to be the continuation of the sensory and motor tracts 
which we have studied in the basis cerebri. The extension of 
the sensory tract upward from the crura into the internal capsule 
is not so clear as is the continuity of the motor tract anteriorly. 
This, denominated by some the peduncular tract, and designated 
in Lect. Y. as the direct cerebral motor tract, can be traced by dis- 
sections, by physiological experiments, by embryology, and 
lastly by the help of pathological processes (descending degen- 
eration) from certain convolutions of the cortex cerebri into the 
anterior half or two-thirds of the internal capsule, into the crus 
cerebri, the pons, the medulla, and (in accordance with the law 



N« "MBC 




Modified from Charcot's diagram, to "how position, relation, and distribution of the intema\ 
capsule as seen in a vertical transverse section of the brain on a level with the greatest de- 
velopment of t o, thalamus opticus, i c, location of internal capsule ; n l, nucleus lenticu- 

• laris; e c, external capsule; d, claustrum ; n c, nucleus candatus ; mkc, motor regions of 
cortex cerebri ; 1, fibres representing the radiation of the internal capsule vertically to the 
motor region of cortex. 

of decussation — vide Lect. IV.), into both halves of the spinal 
cord. The composition and extension of the internal capsule is 
rudely represented in diagram by Fig. 7. Its exact position in 
the hemisphere and its relations to other parts of the encephalon 
are well shown in Fig. 8, modified from a cut in Prof. Charcot's 



332 LECTURES ON LOCALIZATION. 

Lectures on Localization in Cerebral Diseases. This represents 
a transverse vertical section of the hemispheres made through 
the middle of the optic thalamus. The internal capsule is seen 
to lie between the external border of the thalamus and the nu- 
cleus lenticularis of the corpus striatum. In this location the 
bundle is much compressed, and seems to have little or no con- 
nection with the gray bodies just named ; it expands in every 
direction after passing them, and its anterior fibres are ulti- 
mately distributed to the middle regions of the cortex cerebri — 
motor district — embracing the third frontal, the posterior ex- 
tremities of the first and second frontal, the ascending frontal 
convolutions, also the ascending parietal and first parietal con- 
volutions ; also, lastly, to the continuation upon the inner sur- 
face of the hemisphere of the ascending frontal and parietal 
convolutions which make up the paracentral lobule. The pos- 
terior third of the internal capsule is very probably distributed 
to the occipital, temporal and second parietal convolutions — the 
supposed sensory gyri. 

Besides common sensory tracts, the posterior part of the 
internal capsule contains fibres which are directly or indirectly 
connected with the special sense organs, viz., the optic, olfac- 
tory, gustatory, and acoustic. This is shown by the fact that 
total hemi-ansesthesia in man results from lesions involving the 
internal capsule ; from experiments upon animals, whereby cer- 
tain occipital or temporal convolutions being removed, blindness 
or deafness is caused on the opposite side. 

The physiology of the great ganglia, commissural fibres, and 
internal capsule is far from satisfactorily marked out. Many 
glaring contradictions are apparently proved by the experiments 
of different observers. It would appear well settled that the 
corpus quadrigeminum and the corpora geniculata are a part of 
the optic apparatus ; that the nucleus caudatus and the nucleus 
lenticularis have motor functions of some sort. The greatest 
uncertainty exists, I think, concerning the attributes of the 
thalami optici. 

On the other hand, we now know pretty positively that most 
of the sensory paths for the body pass in the posterior part of 
the internal capsule, laceration of this part in animals being 
invariably followed by hemi-ana3sthesia on the opposite side. 
That the thalamus has anything to do with the perception of 
sensations is rendered doubtful by the occurrence of cases in 



LECTUBES ON LOCALIZATION. 333 

which lesions, strictly limited (?'. e., not pressing on adjacent 
parts) to the thalamus have produced no special symptoms. The 
same objection (pathological) can be urged against the view that 
the nucleus lenticularis has important motor functions. That 
the anterior part (two-thirds ?) of the capsule consists of motor 
fibres is likewise quite well established by experiments upon 
animals and by the study of pathological cases.* What the 
functions of the various commissural fibres may be, is, at the 
present time, only a matter of speculation more or less logically 
constructed. 

1. LESIONS OF THE BASAL GANGLIA. 

The generally received statements that lesions of these bodies 
produce definite symptoms — lesions of the nucleus lenticularis 
and nucleus caudatus paralysis, and lesions of the thalamus 
opticus, ansesthesia — are, I think, very questionable. From the 
evidence now before us it seems doubtful if lesions of the nu- 
cleus lenticularis, and of the thalamus, produce any symptoms 
except by exerting pressure upon the internal capsule lying near 
by. At any rate, cases of destruction of large parts of these 
bodies without symptoms are on record. As regards the nucleus 
caudatus, it is possible that its destruction is followed by hemi- 
plegia and secondary degeneration ; but on the other hand, it 
must be admitted that almost all lesions of this body are so 
placed, and of such a nature, as to cause pressure upon the 
motor portion of the internal capsule. This is especially true 
of hemorrhage, as shown by Prof. Charcot in his recent lectures 
on the brain. 

2. LESIONS OF THE INTERNAL CAPSULE. 

These, on the other hand, produce, as shown by the recent 
study of pathological evidence, and by experiments upon ani- 

* Since these lectures were delivered, a brilliant and final proof of the motor 
functions of the anterior part of the internal capsule, and of the continuity of the 
motor convolutions and the direct cerebral motor tract has been advanced by 
the French experimenters, Franck and Pitres (Le Proges Medical, Jan. 19, 1878). 
These physiologists found that by faradizing those parts of the white centre of the 
hemisphere which lie underneath the so-called cortical motor centres, they were 
able to produce definite movements in parts of the body on the opposite side. 
This tract of white matter, constituting the anterior portion of the internal cap- 
sule, contains physiologically distinct fasciculi which are connected on the one 
hand with the motor districts of the cortex, and on the other hand with peripheral 
parts of the body across the median line. 



834 LECTURES ON LOCALIZATION. 

mals, constant symptoms. If the anterior half or two-thirds of 
the capsule be injured, we have hemiplegia on the opposite side 
of the body ; more or less perfect hemiplegia according to the 
exact seat and size of the lesion. It will be readily understood 
that lesions (especially hemorrhage and tumors) of parts ad- 
jacent to the capsule, such as the lenticular and caudate nuclei, 
the white centre of the frontal lobe, etc., may by pressure bring 
about a similar result. Besides paralysis, descending secondary 
degeneration is an inevitable result of lesions of the internal 
capsule. This lesion can be traced downward through the whole 
length of the direct cerebral motor tract so frequently referred 
to before, to the lower end of the spinal cord. Lesions of the 
nucleus caudatus are also said to produce the same results, but 
recent researches (Flechsig) throw doubt on this. 

If the posterior part of the internal capsule be injured directly, 
or indirectly by the pressure of lesions in adjoining regions, 
there is produced anaesthesia, more or less complete, on the 
opposite side, usually with only slight paralysis. If the lesion 
be considerable the anaesthesia is absolute ; i.e., the special 
senses and common sensory nerves lose their function, or more 
properly speaking, impressions coming through these cannot 
reach the perceptive centers. Hemiopia is never (?) thus pro- 
duced, and Charcot explains this by supposing a second semi- 
decussation to take place in some part between the chiasm and 
the internal capsule ; probably in the corpus quadrigeminum. 
A reference to Fig. 6, Lect. V., will, I trust, make this hypoth- 
esis plain. 

Yet a third symptom results from lesions of the internal, cap- 
sule, viz., choreiform movements following hemiplegia and hemi- 
anaesthesia. These movements vary in degree and type from 
true athetosis to ataxia, from chorea to tremor, and constitute 
an interesting symptom-group, well worthy of further study. 
In my own cases of post-hemiplegic chorea, hemi-anaesthesis of 
slight degree was present, and in one case lateral hemiopia. 

Extensive lesions of the central parts of the hemispheres may 
produce, besides the specific signs named above, a number of 
other symptoms. Thus, suddenly produced lesions (hemor- 
rhage, softening) will nearly always cause conjugate deviation of 
the eyes and head. The patient, though insensible, turns his 
eyes and head constantly to one side, toward the injured hemi- 
sphere, and away from the paralyzed side. In spite of a recent 



LECTURES ON LOCALIZATION, 335 

attempt to impeach the value of this symptom of hemispheric 
injury, I am disposed to attach value to it. Great increase in 
the bodily temperature also follows large injuries. 

Other lesions, such as cause pressure, and slowly grow to a 
great size (tumors), cause, in addition to the specific signs de- 
pendent upon their exact location, the change within the eye 
which we call neuro-retinitis, (vide Lect. V.). They will also 
usually produce convulsions. 

As regards the remainder of the white substance, such as the 
central regions of the frontal, occipital, and temporal lobes, 
modern critical study of recorded cases would seem to indicate 
that lesions involving these parts in such a way as not to press 
upon the internal capsule and nucleus caudatus, do not give rise 
to any symptoms ; e.g., an immense abcess may occupy the tem- 
poral and occipital lobes, or the anterior part of the frontal 
lobe, without causing paralysis or anaesthesia. Anatomy and 
experimentation, however, seem to indicate that lesions of the 
occipital and temporal lobes should give rise to sensory symp- 
toms ; and a more careful study of cases of disease in these 
parts is just now a desideratum. 

We do not know any more relative to lesion of the great com- 
missural bundles which unite the two hemispheres and different 
parts of one hemisphere. The cases of congenital absence of 
the corpus callosum on record do not teach anything definite. 

3. LESIONS OF TIIE CEREBELLUM. 

I add a few words relative to another terra incognita in the 
brain, the cerebellum. Its situation is known to all of you, but 
there are a few points in its anatomy to which I would specially 
invite your attention. In the first place, this great mass of 
nervous matter is closely bound down by a strong fibrous cover- 
ing (a bony septum in some animals), the tentorium cerebelli. 
This fold of dura mater probably serves important purposes in 
health, but in case of disease in the cerebellum it causes pres- 
sure-effects to be transmitted chiefly forward and downward. 
This is important to bear in mind when studying the effects of 
cerebellar lesions. Second, the cerebellum is remarkable for 
its numerous connections with other parts of the nervous system. 
Fibres connect each of its hemispheres with the nucleus cau- 
datus and cerebral hemisphere of the opposite side, by means 



336 LECTURES ON LOCALIZATION. 

of the crura cerebelli ad cerebrum. Other fibres, forming 
heavy bundles, make up the crura ad pontem or lateral pedun- 
cles of the organ ; extending deeply into the white and gray 
substances of the mesencephalon. It is probable that each half 
of the cerebellum is thus connected with the opposite half of the 
pons ; possibly some fibres are strictly commissural, i.e., unite 
the two hemispheres of the organ after passing over the pons. 
Lastly, the cerebellum is connected with the medulla and spinal 
cord. It forms, by means of the crura cerebelli ad medullam, 
close connections with the olivary bodies, and with the external 
portion of the lateral columns (near the extremity of the pos- 
terior horns) in the spinal cord. It has been claimed that some 
cranial nerves (third, fourth, and acoustic) have been traced into 
the cerebellum, but the evidence on this point is unsatisfactory. 
Third, the cerebellum overlies highly important organs, and this 
proximity serves to explain much of the semeiology of its lesions. 
In front of it is the corpus quadrigeminum and the tegmentum 
cruris, with its contained vaso-motor (and convulsive ?) centre ;-> 
beneath it the medulla oblongata, with its floor and such vital 
nerves as the pneumogastric and the spinal accessory. 

The physiology of the cerebellum is at the present day quite 
unknown. That it serves for purposes of co-ordination in a 
direct and positive manner is disproved by experimentation and 
pathology ; that it is a centre for the movements of the eyeballs 
(Ferrier) is equally doubtful ; and so is the view that it is the 
seat of psychical attributes of an emotional character. Mitchell's 
hypothesis, that it is a store-house of nerve force for use in 
emergencies, is plausible but unproven. The mechanism and 
purpose of the cerebellar connections is likewise not understood. 

As regards the diagnosis of lesions of the cerebellum, I must 
admit that, in the very numerous symptoms produced by them, 
I do not know of one that is characteristic. In other words, 
lesions strictly limited to the substance of the cerebellum pro- 
duce no definite symptoms : and on the other hand, the symp- 
toms which we observe in cerebellar diseases are the result of 
pressure-effects upon adjacent parts. Thus, the affections of 
sight so common in cerebellar lesions are caused by pressure 
upon the corpus quadrigeminum or the corpora geniculata, and 
also upon the origins of the third, fourth and sixth nerves. The 
nausea, vomiting, and sudden death may be explained by irrita- 
tion and paralysis of the nuclei of the pneumogastric nerves in 



LECTURES ON LOCALIZATION. 337 

the floor of the fourth ventricle ; convulsions, by pressure upon 
the tegmentum cruris ; the imperfect hemiplegia or general 
paralysis, by a similar action upon the motor regions of the 
mesencephalon. The diagnosis (assisted by predominance of 
pain in the occipital region) must be made chiefly by exclusion. 
A symptom of great importance when present is titubation. 
This has been termed cerebellar ataxia, but as a descriptive 
term titubation is better. The patient walks with his feet 
separated, his body bent a little forward and swaying, his hands 
and arms in use to preserve his equilibrium. There is no true 
ataxic jerking, no want of harmony between antagonistic groups 
of muscles, no choreic movements, no tremor.* 



Lecture YTI. 

SUMMARY : — ANATOMY AND LESIONS OF THE CORTEX OF THE BRAIN. — THE 
CHIEF CORTICAL MOTOR CENTRES, AND BKOCA'S SPEECH-CENTRE. — 
LOCALIZED LESIONS OF THE CORTEX CEREBRI ; DIFFUSED LESIONS OF THE 
SAME. • 

Gentlemen : — The cerebral cortex is an immense, spread-out 
ganglion, whose functions are not yet fully or exactly known. 
Like all ganglionic masses, it is composed of ganglion-cells, nerve- 
fibres, blood-vessels, and neuroglia. Its ganglion-cells are gen- 
erally pyramidal in shape the apex of the pyramids being turned 
outward or peripherally. They vary very much in size and in 
precise shape, the largest occurring in convolutions of the 
median parts of the hemispheres. 

This gray cortical layer becoming folded through the process 

- After the delivery of this lecture, Prof. H. Xothnagel of Jena, published (in 
Berliner Uinische Woclienschrift, 1878, Xo. 15) the results of his analysis of more 
than two hundred and fifty cases of cerebellar disease. His conclusions, I am 
happy to say, are substantially equivalent to what has been said above. However, 
Prof. X. is disposed to admit one symptom — cerebellar ataxia— as characteristic of 
injury to the cerebellum or more properly, to one of its sm^ler parts, the superior 
vermiform process. X. says that by cerebellar ataxia wc are to understand a 
perversion of equilibrium closely resembling that observed in alcoholic intoxication ; 
the patient titubates, stands with feet wide apart ; if he be barefooted the toes are 
seen in active motion : and in walking the body sways a good deal, the foot is 
brought down with ball or with heel first irregularly ; closing the eyes sometimes 
makes standing and walking worse, sometimes not. In the recumbent position 
there is no ataxia. In the large majority of cases the upper extremities remain 
free from inco-ordination. 
22 



338 LECTURES ON LOCALIZATION. 

of growth, ultimately presents irregular swellings and depres- 
sions of its surface. The swellings are called convolutions or 
gyri ; the depressions, fissures or sulci. Some of the sulci are 
very deep, and receive special names. It should not be forgot- 
ten that the bottom of every sulcus is formed by the same 
ganglionic gray matter as the prominent parts of gyri. 

These gyri are so grouped and separated by large sulci, that 
we are now enabled to make a successful topographical study of 
the apparantly confused mass of convolutions ; and in my brief 
description of the cortex cerebri I shall almost follow Ecker's 
classification of its parts. Thus in each hemisphere we have 
four lobes or groups of gyri, viz., the frontal, parietal, temporal, 
and occipital lobes. Separating these lobes are three large and 
constant fissures : the fissure of Sylvius, between the frontal 
and temporal lobes ; the fissure of Rolando (or central f.), sepa- 
rating the frontal and parietal lobes ; and the occipito-parietal 
fissure in the inner face of the hemisphere, limiting the occipital 
and parietal lobes. 

Besides, we recognize four lobules, viz., lobulus centralis 
(island of Reil at the bottom of the fissure of Sylvius), lobulus 
paracentralis, lobulus cuneus, and lobulus quadratus, on the 
inner surface of the hemisphere. The paracentral lobule is 
made up almost wholly of the upper (inner) ends of the ascend- 
ing frontal and ascending frontal convolutions as they dip into 
the great longitudinal fissure. 

For a full account of these parts I would refer you to Ecker's 
monograph on the cerebral convolutions, to Ferrier's work on 
the functions of the brain, and to the latest edition of "Dalton's 
Physiology." A few of the convolutions in these lobes and 
lobules are of importance in the study of localization, and I 
must briefly describe them. 

First, the third and ascending frontal convolutions. The 
former of these (f. 3. Fig. 9) constitutes the lower tier of gyri in 
the external aspect of the frontal lobes, and forms the antero- 
cuperior lip of the fissure of Sylvius. Its posterior part and its 
continuation into the island of Reil certainly have a very close 
connection with the function of written and spoken speech. The 
ascending frontal gyrus (A, Fig. 9) forms the posterior limit of 
the frontal lobe, and lies against the fissure of Rolando. Ecker 
calls it the anterior central convolution, but in common with 
Prof. Charcot and his pupils, I prefer the former designation. 



LECTURES ON LOCALIZATION. 



339 



Immediately behind the fissure of Eolando, extending almost 
vertically, is the ascending parietal gyrus, or the posterior cen- 
tral convolution of Ecker. These two gyri, the ascending frontal 
and parietal, are intimately connected with movements of the 
face, arm, and leg ; so-called centres for the face existing in the 
lower ascending frontal, centres for the upper extremities being 
found in its middle portions and in the ascending parietal gyrus ; 
while the centres for the movements of the lower limbs are in 
the upper (inner) extremities of both these gyri, and in the next 
parietal convolution near the median fissure, viz., the superior 
parietal (p. 1, Fig. 9). 

The last gyrus of clinical importance is the next below the 
inferior parietal and its extension toward the occipital lobe, the 
angular gyrus, so-called (P2 Fig. 9). Some recent clinical and 




Fig. 9. 
Modified from Ferrier : letters and figures the same.— S, Fissure of Sylvius ; e, Fissure of 
Rolando ; po, Parieto-oceipital fissure. A, Ascending frontal gyrus ; B, Ascending parietal 
gyrus ; F 3 , Third frontal gyrus ; P 2 ', Gyrus angularis. Circle I., Seat of lesions which (on 
the left side) cause aphasia. Circle II., Seat of lesions which convulse or paralyze the upper 
extremity of the opposite side. Dotted Circle III., Seat of lesions which probably convulse or 
paralyze the face on the opposite side. Dotted oval IV., Seat of lesions which probably con- 
vulse or paralyze the lower extremity of the opposite side, These districts receive their blood 
supply chiefly from the middle cerebral artery. 



340 LECTURES ON LOCALIZATION. 

post-mortem facts would seem to connect it with movements of 
the eyelids and upper face. Besides, the paracentral lobule is 
of importance to us, because we know that its destruction is 
followed by descending degeneration. 

The cerebral convolutions are supplied with blood by branches 
of the anterior, middle, and posterior cerebral arteries, and an 
exact knowledge of the distribution of these trunks and their 
ramification is of the utmost importance in the study of localiza- 
tion of lesions, inasmuch as one of the most common pathologi- 
cal processes by which destruction of convolutions is caused, is 
embolism, or plugging of one of these arteries. 

In general terms, the anterior cerebral artery supplies the 
inner face of the hemisphere as far back as the occipito-parietal 
fissure ; the first, second, and (very partially) the ascending 
frontal convolutions. 

The middle cerebral artery, or the Sylvian artery, is the most 
important physiologically, as it supplies all the convolutions 
mentioned above as concerned in the production of voluntary 
movements, viz., the third and the ascending frontal, ascend- 
ing, first and second parietal convolutions. Easily recognized 
branches of the middle cerebral artery furnish blood to the 
third frontal (first branch in the fissure of Sylvius), to the ascend- 
ing frontal, to the ascending parietal ; a fourth branch extends 
as far as the angular gyrus, and a fifth supplies the first tem- 
poral convolution. 

The posterior cerebral artery supplies the remainder of the 
temporal lobe and the whole of the occipital. 

It might not quite be out of place to state here that, according 
to Charcot and Duret, the basal ganglia of the brain receive their 
blood through small branches which leave the great arteries 
very near the origin of the circle of Willis. The anterior part 
of the nucleus caudatus is supplied by arterioles derived from the 
anterior communicating artery, and from the first portion of the 
anterior cerebral artery. The nucleus lenticularis and the 
anterior part of the thalamus opticus are vascularized by 
branches of the trunk of the middle cerebral artery before it 
enters the Sylvian fissure. The larger part of the optic thalamus 
is supplied by vessels coming from the second portion of the 
posterior cerebral artery beyond the circle of Willis. Finally 
the inner aspects of the thalamus and the walls of the third 
ventricle receive branches from the posterior communicating 



LECTURES ON LOCALIZATION. 341 

artery, and from the first portion of the posterior cerebral artery 
within the circle of "Willis. 

To return to the arteries of the cortex. Ramifying in the pia 
covering the convolutions, they penetrate the nervous tissue in 
a peculiar manner, in the shape of long and straight branches, 
which supply the various layers of the cortex by means of hori- 
zontal branches, and ultimately, in small numbers, and greatly 
reduced in size, reach the white substances. A most important 
peculiarity in the superficial and deep cortical circulations is 
the absence of anastomosis between arteries of any great size. 
As to the exact amount of anastomosis there is a difference of 
opinion between the two original observers in this matter — both 
equally competent — Duret, of Paris, and Heubner, of Leipzig, 
The former maintains, and pathology supports him, that there is 
next to no anastomotic circulation upon or in the cortex (except 
through capillaries) while Heubner thinks that considerable 
branches of the great cerebral vessels open into one another 
upon the surface of the brain. The importance of this point for 
the prognosis of embolism of the cerebral arteries is enormous, 
and for my part I would say that I am disposed to consider 
Duret's statement as more applicable to practice. 

I now pass to a very short account of the physiology of the 
cortex. My statements upon this matter will be all the briefer 
because an excellent and full account of the physiology of the 
cerebrum is accessible to all of you in Prof. Dalton's " Treatise 
on Physiology." Dr. Dalton himself has taken an honorable 
part in the researches which have, in the last five years, revealed 
unsuspected properties in the cortex of the brain. 

First. We now know, since the experimental researches of 
Fritsch and Hitzig (1870), and of Ferrier (1873), that the cortex 
of the brain is excitable ; i. e., that galvanization or faradization 
of the cortex produces muscular movements in the body and 
limbs. This fact, standing out in direct contradiction to the 
teaching of all physiologists from Magendie and Muller, is a 
monumental acquisition to biological science. 

Second. Very numerous researches by Hitzig, Ferrier, and a 
host of others, appear to have established beyond question that 
a certain relation exists between well-defined portions of the 
cortex of one hemisphere and limited muscular groups (almost 
individual muscles) in the opposite half of the body. The areas 
of convolutions whose irritation by electricity is followed by 



342 LECTURES ON LOCALIZATION. 

definite movements of peripheral parts have been denominated 
motor centres, or psycho-motor centres ; and a large number of 
these centres have been determined by Prof. Ferrier and by Prof. 
Hitzig, upon the brains of dogs, cats, and living monkeys, whose 
brains bear a certain resemblance to the cerebrum of man. 
"While knowing of a few opposing experiments which would seem 
to show that there is no constant relation between the spot irri- 
tated and the resultant movement, I am bound, by the weight of 
evidence and by the wonderful accord between the researches of 
various experimenters, to accept the facts as stated above. 

Third, The excitable district of the brain is its median group 
of convolutions, including (as sketched upon a human brain, 
after experiments upon monkeys) the second, third, and ascend- 
ing frontal convolutions, the ascending and first parietal convo- 
lutions. This excitable district or zone includes, as you perceive, 
gyri which receive their blood-supply by branches of the middle 
cerebral artery, with the exception of the second frontal gyrus. 
As my chief object is not physiological teaching, I prefer simply 
to enumerate the cortical centres as laid down by Ferrier, not 
encumbering a diagram with a representation of them. 

On the posterior extremity of the third frontal gyrus, near the 
fissure of .Sylvius, is a centre for the movement of the lips and 
tongue (a speech-centre according to the teachings of pathology) ; 
this is numbered 9 and 10 on Ferrier's plate. Next in order, 
upon the lower part of the ascending frontal convolution are 
centres for movements of the elevators and depressors of the 
angle of the mouth ; numbered 8 and 7. Still higher on this 
gyrus is a centre for movements of the forearm and hand ; num- 
bered 6. Upon the upper two-thirds of the ascending parietal 
convolution are several centres for complex movements of the 
hand and wrist ; designated by Ferrier, a, b, c, d. Much farther 
forward, upon the hemisphere near the great longitudinal fissure, 
is an extensive region embracing the posterior parts of the first 
and second frontal gyri, governing lateral movements of the 
head, elevation of the eyelids, and dilatation of the pupil ; num- 
bered 12. Immediately behind this, near the longitudinal fissure, 
upon the posterior extremity of the first frontal convolution, is a 
centre for extension and forward movements of the hand and 
arm ; numbered 5. The posterior (inner) ends of the ascending 
frontal and ascending parietal convolutions contain centres (not 
clearly differentiated) for complex movements of the arms and 



LECTURES ON LOCALIZATION. 343 

legs together ; numbered 2, 3, and 4 on Ferrier's plate. Finally, 
behind these on the superior parietal lobule is a centre for 
movements of the leg and foot ; numbered 1. 

The sensory centres of Ferrier occupy various parts of the 
inferior parietal lobule, the gyrus angularis, the second occipital, 
and first temporal convolutions. Although the experiments of 
various observers make it exceedingly probable that these 
inferior and posterior portions of the hemisphere are connected 
with general and special sensory functions, yet, as human 
pathology has so far thrown no light upon these questions, I 
shall hereafter confine myself to the study of the motor districts 
of the convolutions. 

Not to weary you by the citation of the now very numerous 
cases in which localized cortical lesions, as tumors, abscesses, 
clots, softening, pressure-effects from bone or thickened meninges, 
have given rise to definite symptoms, in close or even almost 
exact agreement with the data obtained by faradizing the cortex, 
I shall state in a general manner the tendency of these recent 
clinical and post-mortem studies. 

In the first place, it appears almost absolutely certain that in 
man a lesion involving the posterior part of the third frontal 
convolution (on the left side usually) causes aphasia; i.e., 
impairment or loss of articulate speech, or even of language in 
general. It would seem, besides, that (1) lesions of the same 
part on either side of the brain produce paresis of many muscles 
concerned in lingual and pharyngeal movements ; (2) that lesions 
of the anterior folds of the island of Reil, convolutions which are 
continuous with the third frontal, may also produce aphasia ; 
and that (3) loss of speech may result from injury to the white 
substance lying between the third frontal gyrus and the basis 
cerebri. I believe, you observe, in a not too limited localization 
of the motor functions exerted in language, and would graphically 
represent this by the circle marked I. in Fig. 9. 

In the second place, lesions limited to the inferior portions of 
the ascending frontal and parietal gyri have produced spasmodic 
and paralytic phenomena limited to the upper extremity of the 
opposite side. I am disposed to admit as highly probable that 
these parts are connected, in the healthy living man, with the 
various voluntary movements of the arm and hand. This zone 
is represented in Fig. 9 by circle II. 

I am not prepared to go further in admitting pathologically 



344 LECTURES ON LOCALIZATION. 

proved cortical centres, but would add that there are some 
reasons for believing that future autopsies will locate one centre 
for the external facial muscles just forward of the two centres 
named above, viz., the region included in the dotted circle III. ; 
and another for movements of the legs upon the upper parts of 
ascending frontal and parietal, as roughly indicated by the 
dotted oval, IY. 

As regards sensory cortical centres, I have already said that 
we have as yet no pathological data for their study. 

Having thus expressed myself about the question of cortical 
centres in man, I pass to the more clinical study of symptoms 
observed when the cortex is injured. 

First. What are the symptoms of localized lesions involving 
the cortex alone, or the cortex and a minimum of subjacent 
white matter ? The symptoms differ vastly in accordance with 
a rule laid down years ago by Brown-Sequard, according as the 
lesion is an irritative or destructive one ; and besides, they vary 
according as the lesions are within the excitable cortical region 
(defined supra) or outside of it. We can clear the ground pretty 
safely at once by admitting that lesions irritating or destroying 
convolutions not embraced in the motor zone produce no symp- 
toms at all. Large parts of the frontal, temporal, or occipital 
convolutions may be injured or utterly destroyed without the 
patient showing during life any special symptoms of organic 
cerebral disease. This statement is based upon the study of 
recent cases only, though I doubt not that in the literature of 
the century, numerous apparently contradictory cases might be 
collected. In considering this negative proposition, one proviso 
must be borne in mind, viz., that if the lesions of these unexcit- 
able districts involve the dura mater, convulsions and localized 
cephalalgia may occur. Of this I have seen one marked example. 

We are now prepared to study the symptoms of lesions in the 
excitable or motor zone of the hemispheres, as indicated by the 
various circles in Fig. 9. 

1. The symptoms of an irritative lesion of these parts consist 
in convulsions, with or without subsequent transient paralysis ; 
e. g., such a lesion in circle III. (Hitzig's case) would give rise to 
spasmodic movements in the superficial muscles of the face, on 
the opposite side, with slight paralysis. Irritative lesions of 
the regions inclosed in circles II. and IV. will cause convulsions 
limited to, or first appearing, in the hand and arm, or foot and 



LECTURES ON LOCALIZATION. 345 

leg, of the opposite side. As regards circle L, Broca's speech 
centre, we know little of the effects of its pathological irritation. 
In one case which I have placed on record, a thickening of the 
meninges involving the third frontal convolution of the left side 
produced intermittent and incomplete aphasia. 

It was by the close study of the clinical and pathological 
aspects of cases of localized epilepsy (fingers and hands), that 
Dr. J. Hughlings Jackson was enabled to form his theory of 
motorial discharges from irritation of the cortex cerebri, and 
thus pave the way for Ferrier's admirable researches. Dr. 
Jackson must, I think, be considered, after Prof. Broca, as the 
founder of our present growing doctrine of cortical localizations. 

2. Destructive lesions of portions of the excitable district 
produce paralysis in peripheral parts across the median line. 
The symptoms will, to a certain extent, correspond with the 
precise location of the lesions, very much as in irritative lesions ; 
e. g., embolism of the first branch of the middle cerebral artery 
on the left side will cause softening of the posterior part of the 
third frontal gyrus, with the symptom aphasia. A destructive 
lesion of the principal part of the motor zone on the right side 
will produce left hemiplegia without aphasia ; but if this lesion 
occupy the left hemisphere, loss of speech will co-exist with 
the paralysis. 

It must be added that secondary descending degeneration 
ensues after destructive lesions of the motor regions of the cor- 
tex, and that we have late contracture or rigidity of the paralyzed 
limbs as part of the symptom-group. 

Negative characters of these cortical lesions are, preservation 
of sensibility in the paralyzed parts, and (except with epileptic 
attacks) preservation of consciousness, and incompleteness of 
paralysis. 

In the next place, let us inquire what are the symptoms pro- 
duced by diffused lesions of the cortex. As exemplified in acute 
meningitis, the chief symptons are delirium, convulsions, and 
pain ; evidences of intense irritation. The coma and paralysis 
which follow may in some degree be caused by impaired nutrition 
of the cortex, but more probably by circulatory and tension- 
changes in the whole encephalic mass. 

There is a much better disease for studying the effects of 
lesions of the surface of the brain, both irritative and destructive 
—I mean general paralysis of the insane, or, anatomically speak- 



346 LECTURES ON LOCALIZATION. 

ing, diffused, chronic, meningo-encephalitis. The affection is 
very common, and has been thoroughly studied, clinically and 
pathologically. From these studies we learn that in the first 
stage of the affection there occur fibrillary contractions in 
many muscles of the tongue, face and limbs ; that speech is 
made tremulous and jerky ; that there is over-ideation and even 
acute delirium ; that gradually memory and judgment become 
impaired, and a semi-paralytic and semi-ataxic condition 
develops in the limbs. Later the mental faculties are abolished ; 
a stage of dementia with occasional gleams of delirium (exalted 
notions), and integrity of the organic functions characterizes the 
disease. The attempt is now being made to show that when the 
meningo-cortical changes are limited to the frontal lobes the 
symptoms are mainly psychical ; when the lesion involves the 
motor districts alone we observe abundant fibrillary tremors 
and pseudo-paralysis ; and, finally, if the occipital lobes are 
affected sensory symptoms (hallucinations) predominate. As 
yet not much support has been obtained for such a distinction, 
which appears very tempting upon physiological grounds. It 
should not be forgotten, in using cases of general paralysis for 
the study of the question of localization, that the disease is one 
in which lesions exist in many parts, or almost all the parts of 
the cerebro-spinal axis. 

The question of the localization of functions in the cerebral 
convolutions, and that of the possibility of diagnosticating their 
lesions is, as yet, in its infancy ; we need numbers of exact 
observations to decide it one way or the other. Just now, I 
believe that the presumption is in favor of a positive answer ; 
there are many facts supporting this affirmative. The clinical 
and post-mortem facts have just been referred to, and I shall 
close the lecture by recapitulating the various anatomical, phys- 
iological, and pathological evidence in favor of the existence of 
motor centres in the cortex. 

1. Coarse anatomy enables us to trace bundles of fibres up- 
ward from the motor tract of the medulla and pons, into the 
internal capsule as far as the convolutions which are grouped 
about the fissure of Bolando. By its aid we can also trace sen- 
sory nerve fasciculi from the posterior regions of the pons to 
the occipital and temporal lobes, and their cortex. Such gross 
dissections are, however, condemned as unreliable by some 
authorities. 



LECTURES ON LOCALIZATION. 347 

Microscopic anatomy shows that the so-called motor gyri are 
rich in large cells ; nay, that they alone contain the " giant 
cells " of Betz, that is, ganglion cells, which in size and number 
of processes bear a remarkable resemblance to the unquestiona- 
bly motor ganglion cells of the anterior horns of the spinal cord 
and the medulla oblongata. In the motor convolutions these 
giant cells are found in little clusters of three, lire', or more, in a 
section, imbedded among the large ganglion cells of the third 
layer. 

2. Experimental physiology teaches us that electrical irrita- 
tion of this zone, and of this zone only, produces muscular con- 
traction in parts on the other side of the median line ; and, 
further, that this zone may be divided into a number of " cen- 
tres " for various small parts, tongue, face, arm, leg, etc. * By 
experimentation we also learn that slicing or burning off these 
cortical centres produces partial paralysis of peripheral parts 
on the opposite side of the body, with precisely the same corre- 
spondence between centres and muscular groups as the irritative 
experiments demonstrate. 

By the latter mode of experimenting applied to the occipital 
and temporal convolutions (Ferrier, H. Munk, and others), it is 
made highly probable that there is a certain relation between 
parts of these gyri and the organs of special and general sensi- 
bility across the median line. 

3. Pathological anatomy (recent cases) demonstrates (a) that 
destructive lesions of the motor regions of the cortex (and of the 
paracentral lobule) produce descending degeneration through- 
out the direct cerebral motor tract extending into the lateral 
columns of the spinal cord ; and (b) that there is a remarkable 
correspondence between certain localized spasmodic and paraly- 
tic symptoms observed during life, and lesions irritating or 
destroying certain definite spots in the motor zone of the cortex. 

* Still more recent researches by MM. Franck and Pitres show that after removal 
of the cortex in the excitable zone, faradization of those portions of white sub- 
stances which are then exposed (anterior half of the internal capsule) gives rise to 
similar (in kind and in distribution) movements in peripheral parts across the 
median line. 



348 LECTURES ON LOCALIZATION. 

Lectuee VIIL 

SUMMARY : — SURGICAL ASPECTS OF THE QUESTION OF CEREBRAL LOCALIZA- 
TIONS — CRANIO-CEREBRAL TOPOGRAPHY, AND ITS UTILIZATION IN DIAGNO- 
SIS AND FOR OPERATIVE PROCEDURES. 

Gentlemen : — The question of the utilization of the doctrine 
of localization in surgery remains for study. This, the most 
novel part of the subject, is, I think, of great present interest 
and of much promise in the future. Already several brilliant 
surgical operations have been performed upon indications de- 
rived from the newly acquired knowledge of cranio-cerebral 
topography. By this term we mean the determination of the 
relations between the external surface of the skull and the prin- 
cipal gyri and sulci of the brain. So little was done toward 
ascertaining these relations that up to 1861 the position of the 
fissure of Rolando relative to the coronal suture was wholly un- 
known. In that year Prof. Broca invented a scientific procedure 
for the study of the subject ; he inserted pegs into the cerebral 
substance through holes drilled into the skull at given points, 
and then, removing the skull-cap carefully, was enabled to deter- 
mine exactly what convolutions corresponded to the pierced re- 
gions of the skull. He thus discovered that the parieto-occipital 
fissure lies under the lambdoid suture, and that the fissure of 
Rolando slopes backward, so that its posterior extremity is 
placed at more than forty millimetres behind the coronal suture. 
Since that year the subject has been thoroughly studied by 
Broca, Bischoff, Heftier (1873), Prof. Turner, of Edinburgh 
(1874), Ch. Fere and Broca (1875), and others. Perhaps the 
best and most applicable of these contributions is that of Fere, 
and I shall follow it closely in the following remarks. It should 
be borne in mind that for purely anthropological purposes, the 
determination of the relation of gyri and sulci to certain sutures 
or processes of the bare skull is sufficient ; but that for use in 
the regional diagnosis of cerebral injuries, and in practical 
surgery, the cranial landmarks should be such as are easily 
determined upon the scalp and face of the living man. The 
resume of cranio-cerebral topography which I offer for your 
guidance is based upon the latter principle of study. 

As shown in Fig. 10, I shall sketch the situation of the prin- 
cipal convolutions, fissures, and central gray bodies of the cere- 
brum upon an outline figure of the profile of a skull. The skull 



LECTURES OX LOCALIZATION. 349 

is represented as resting upon a peculiar plane, one passing 
under the condyles of the occipital bones and the alveolar pro- 
cesses of the superior maxilla? — the alveolo-condyloid plane of 
Br oca. Upon this horizontal line, which can be determined 
with reasonable accuracy in the living human being, we erect 
other lines and measure distances which enable us to solve 
almost the whole problem. 

1. A vertical line (a) drawn from the alveolo- condyloid plane 
through the external auditory meatus upward will pass through, 
or very near to, the bregma or line of junction of the frontal and 
parietal bones at the vertex ; it passes through the anterior 
(lower) extremity of the fissure of Rolando. 

2. If from the upper end of this vertical line A, we measure a 
distance of 45 mm. backward toward the occiput and draw a 
descending vertical line (1-2), we mark out the location of two 
most important parts of the cerebrum, viz., the posterior ex- 
tremity of the fissure of Rolando, and the posterior limit of the 
thalamus opticus in the hemisphere [at c)]. 

3. To conclude with the occipital end of the skull ; if we can 
make out with the finger the lambdoid suture at the median 
line, we thus learn the situation of the subjacent occipitoparietal 
suture, which separates the parietal and occipital lobes. 

4. The last vertical line worth noting is one drawn at a dis- 
tance of 30 mm. forward of the auriculo-bregmatic line. This 
vertical line (3-4) will pass through the middle fold of the third 
frontal convolution (just forward of the speech centre), and will 
also indicate the anterior limit of the central cerebral ganglia, 
viz., the head of the nucleus caudatus in the hemisphere [at (d~\. 

5. The upper level of the central cerebral ganglia may be 
quite exactly indicated by a horizontal line drawn at a distance 
of 45 mm. below the surface of the scalp at the bregma (or 35 
below the surface of the. bare skull at the same point). This 
line ( 7-8 1 also extends across the middle regions of the motor 
district of the convolutions, containing centres for the face and 
upper extremities. 

6. The external angular process of the frontal bone, not diffi- 
cult to define in the living subject, is the starting-point of 
another horizontal line (5-6), whose posterior extremity passes 
a little below the lambdoid suture. Upon this horizontal line 
we can, by measurement, determine the location of certain parts. 
Thus, at a distance of 18 or 20 mm. behind the external angular 



350 



LECTURES ON LOCALIZATION. 



process lies the folded part of the third frontal convolution (a). 
This point in many heads will correspond with the vertical 
line 3^4 




Fig. 10. 
Outline of skull resting upon the alveolo-condyloid plane of Broca ; modified from Topinard 
{Anthropology). Vertical line a, or atiriculo-bregmatic. Line 9-10 drawn parallel to the plane 
of Broca. Upon this line, at a distance of 45 mm. posterior to the bregma, a vertical line, 
1-2, will pass through the upper (inner) end of the fissure of Rolando, b b, and through the 
posterior extremity of the thalamus opticus, (c). A third vertical line, 3-4, drawn at 30 mm. 
forward of the bregma, will pass through the fold of the third frontal gyrus, a, and through 
the head of the nucleus caudatus (d). The horizontal line 7-8, at 45 mm. below the bregma 
(scalp), indicates the upper limit of the central ganglia. The third horizontal line 5-6, pass- 
ing through the external angular process of the frontal bone and the occipito-parietal junction, 
approximately indicates the course of the fissure of Sylvius, and serves for measurements. 
At 18 or 20 mm. behind the ext. ang. process on this line is the speech centre of Broca ; 5 to 8 
mm. behind the intersection of 3-4 and 5-6, is the beginning of the fissure of Sylvius, and at 
28 or 30 mm. behind this intersection is the lower end of the fissure of Rolando, b b, placed a 
little too far back in the cut. At x (near 6), near the median line, is the location of the 
occipito-parietal fissure. 

7. The situation of the fissure of Sylvius may be approximately 
ascertained in the following manner : Its middle portion extends 
horizontally, almost under the upper part of the squamous 
suture, which in the living subject is to be found a little below 
the horizontal line 5-6. The anterior extremity or beginning of 
the fissure of Sylvius is a little below this horizontal line, at a 
distance of some 5 to 8 mm. posterior to the intersection of 3-4 
and 5-6, and consequently about 22 or 25 mm. anterior to the 
auriculo-bregmatic line a. Lastly, according to Turner, the 
parietal eminence almost always overlies the supramarginal 
gyrus (P ; , Fig. 9), consequently the posterior extremity of the 
fissure of Sylvius is likewise in this vicinity. 



LECTURES OX LOCALIZATION, 351 

8. The angular gyrus is to be found below and behind the 
parietal eminence, a little above the horizontal line drawn from 
the external angular process (o-6). 

9. The anterior (lower) end of the fissure of Eolando lies at a 
distance of 28 or 30 mm. behind the line 3-4, and a little above 
o-G. It is therefore a few mm. anterior to the vertical line A. 

The application of these data to practical medicine and sur- 
gery is quite obvious. 

In medical cases, when tumors of the skull develop externally, 
we may determine by craniocerebral topography whether their 
extension inward can give rise to the motor symptoms which 
are present (convulsions and paralysis), according as the excit- 
able districts of the brain are threatened by extension of the 
growth from the inner surface of the skull, or not. 

In surgery, the utility of cranio-cerebral topography is much 
greater. 

For example, as far back as 1871, Professor Broca was able to 
correctly diagnosticate an abscess of the left third frontal con- 
volution, and was successful in trephining directly over it. In 
1876, Proust and Lucas-Championniere successfully trephined 
the skull, in two cases, for the removal of fragments which were 
compressing the ascending frontal and parietal convolutions, 
and causing paralysis. 

In the case of a patient who is paralyzed on one side of the 
body, after an injury to the skull, the following considerations 
might justify, or contra-indicate an operation for the removal of 
bone, of blood, or of pus : 

1. If the hemiplegia (or hemispasm) be very complete, it is 
probable that the injury to the brain is considerable in extent, 
and extends deeper than the special centres for the face, arm, 
and leg. 

2. If the externally evident injury be over non-excitable con- 
volutions, and the paralytic or spasmodic phenomena be marked, 
it is more than probable that the brain is torn or compressed at 
other points than under the seat of injury, and an operation is 
contra-indicated. 

3. If the paralytic or convulsive symptoms be on the same 
side as the evident cranial injury, it is probable that there are 
cerebral lesions on the other side produced by cord re-coup, hence 
interference will be undesirable. 

4. Even if a cranial injury be directly over excitable convolu- 



352 LECTURES ON LOCALIZATION. 

tions, if the resulting paralysis or convulsions be accompanied 
by marked anaesthesia, an operation cannot be expected to do 
much good, because the presence of anaesthesia makes it highly 
probable that the white substance of the hemisphere (pos- 
terior half or third of the internal capsule) is involved in the 
lesion. 

5. A favorable indication for trephining is when aphasia 
supervenes immediately, or in a few weeks after an injury to the 
skull in the region of the left third frontal convolution (see 
Fig. 10). It is extremely likely, in the first case, that a clot or 
spicule of bone will be found compressing or lacerating the 
centre for speech ; in the second, that an abscess has formed in 
the same part (Broca's case). 

6. Another combination of symptoms which makes an opera- 
tion desirable, and holds out a hope of its being successful, is 
when an injury to the skull over the fissure of Rolando on one 
side is accompanied by slight hemiplegia, or by paralysis of the 
face, or arm, or leg, or any two of these parts combined, on the 
opposite side of the median line, without anaesthesia. Under 
such circumstances, the probabilities almost amount to certainty 
that the centres for (see Fig. 9) the face, arm, and leg are sepa- 
rately or collectively involved in the lesion (cases of Proust and 
Lucas-Championniere). 

7. A contra-indication to operative interference, even in ap- 
parently favorable cases, would be symptoms of basal lesions, 
such as palsy of cranial nerves, neuro-retinitis, Cheyne-Stokes 
respiration, and vomiting. 



THE DIAGNOSIS OF PEOGEESSIYE LOCOMOTOE 

ATAXIA.* 

Gentlemen : — The diagnosis of sclerosis of the posterior 
columns of the spinal cord, or, clinically speaking, of progressive 
locomotor ataxia, is one which ought to be made readily by all 
practitioners; and yet the experience of specialists is to the 
effect that mistakes in this matter are very common. Conse- 
quently it may be worth our while to consider the means of cor- 
rectly diagnosticating this terrible disease, by a short and clear 
study of its capital symptoms, and their grouping. 

It has seemed to me that the causes of mistaken diagnosis are 
two-fold : 

First— Medical men generally do not fully appreciate the value 
of the symptom fulgurating pains, as indicative of disease in 
the posterior columns of the spinal cord. This want of clear 
understanding leads to calling the first stage of locomotor ataxia 
by such names as "rheumatism," "neuralgia," etc. 

Second — Practitioners have in some manner acquired an 
exaggerated notion of the value of another symptom, viz., 
staggering or falling when the patient's eyes are closed. This 
second error conduces to calling a variety of morbid states by 
the name of an incurable disease. Even the symptom ataxia, I 
hope to show, is not to be accepted as pathognomonic of the 
disease in question. 

Having these views of the reasons why one of the most defi- 
nite of spinal diseases is so often ignored, or wrongly attributed 
to the patient, you may understand why I seem to make my 
clinics the means of studying semeiology in detail and critically. 
It has seemed to me, for several years, that among the many 
desiderata in the medical curriculum, none is more important 
and urgent than that students and practitioners should devote 
themselves more to analytical semeiology. This exhaustive 
study of symptoms is to practical medicine very much as gen- 
eral histology is to the great sciences of anatomy and physi- 

- From A Series of American Clinical Lectures, edited by E. C. Seguin, M.D. 
Volume III., No. XII. New York, Nov. 13, 1878. 
23 



354 PROGRESSIVE LOCOMOTOR ATAXIA. 

ology. It is a matter of constant surprise how seldom symp- 
toms (especially nervous symptoms) are determined with 
scientific accuracy by physicians ; and yet the symptoms of dis- 
ease are the data from which we reason inductively to a diagnosis. 
If all the symptoms be carelessly observed, how insecure must 
the conclusion be. And if one symptom is erroneously deter- 
mined or interpreted, the whole fabric of diagnosis, in many 
cases, falls to the ground like a house of cards. As an incentive 
to further analytical study of the symptoms of disease, I may 
add, without exaggeration, that, with our present knowledge, the 
most exact and conscientious examination of a patient sometimes 
fails to furnish the elements for more than Avhat I am in the 
habit of calling a diagnosis of probability. 

But to return to our subject. I propose studying it in the 
following manner : First — Enumerate the symptoms of progres- 
sive locomotor ataxia, and classify them into those which are 
important for diagnosis, and those which are unessential. Sec- 
ond — Group these symptoms into the recognized stages of the 
disease, and illustrate by cases the diagnosis in each stage. 
Third — Consider the differential diagnosis between * locomotor 
ataxia and a few conditions which resemble it, and which are 
sometimes taken for it. 

I. The symptoms of progressive locomotor ataxia are the fol- 
lowing : 

(a) Symptoms of real utility in diagnosis : 

Fulgurating pains. 

Hyperesthesia. 

Anaesthesia. 

Ataxia. 

Paralysis of ocular muscles. 

Absence of tendon reflex.* 

(b) Other symptoms, not essential to diagnosis : 

Atrophy of the optic nerves. 

Pupillary changes. 

Disorders of various cranial nerves. 

* Absent tendon reflexes are placed low, by the author, because the same 
symptom is also present in myelitis anterior, diphtheritic myelitis, and some 
neural diseases, besides being apparently the normal state in a few healthy 
people.— [R. W. A.] 



PROGRESSIVE LOCOMOTOR ATAXIA. 355 

Numbness in lower and upper extremities. 

Peculiar sensations under feet. 

Staggering or falling when eyes are closed. 

Sense of constriction about limbs or trunk. 

Paresis of bladder and rectum. 

Increase and decrease of sexual excitability. 

Kectal, vesical, gastric and laryngeal " crises." 

Arthropathies. 

Dementia. 

Muscular atrophy. 

The diagnostic symptoms* are worthy of a full description, 
since their clear appreciation is so important : 

1. By fulgurating pains we mean abnormal sensations having 
the following characters : They are painful sensations, varying 
in degree from the feeling produced by the prick of a needle 
to the most excruciating agony. Patients describe quite a 
variety of these fulgurating pains ; some are like needle-pricks, 
others like knife-cuts, perpendicularly or longitudinally in- 
flicted ; others resemble the crushing of muscles and bones, yet 
others are as if a given piece of nerve were pulled or rubbed, 
and some are like the working up and down of a bolt or a wire 
in a given space in the limb. However varied in character, 
these pains are always sudden, localized, repeated and vagrant. 
They are so sudden in their appearance that a strong man is 
surprised into a loud exclamation of pain by their appearance, 
while feeling otherwise well ; hence the term fulgurating pain. 
They are localized in several senses. First, they make their 
appearance always (?) in the lower extremities, at any rate in 
those parts which are later to become ataxic* Second, they are 
localized in circumscribed regions of tissue, usually the skin. 
In the vast majority of cases rounded or oval spots in the foot, 
thigh or leg, are the seat of fulgurating pains. In other instances 
a circumscribed mass of dee*per tissue (muscle or bone, or joint 
apparently) is the seat of tearing or crushing pain. These pains 
are repeated ; that is to say one patch of skin, or mass of deeper 
tissue, is the seat of a succession of stabbing or crushing pains, 
occurring every few moments for minutes, hours or days. For 
example, a spot the size of a silver dollar upon the instep or 
calf may be the theatre of an agonizing paroxysm of pain ; in- 
numerable acute darts of pain appearing in the region for one 



356 PROGRESSIVE LOCOMOTOR ATAXIA. 

night or twenty-four hours. Lastly, fulgurating pains are 
vagrant. No one nerve trunk is their habitual seat, but any 
portion of the extremities may be visited by them. Patients 
usually give up in despair the attempt to show you every spot 
in which they have suffered; and they generally indicate as 
foci of pain the heel, instep, and thigh. If we consider the 
pathological anatomy of the disease, we easily understand why 
almost every sensory nerve of the affected extremities should at 
various times react to the irritation to which its rootlets are 
subjected in the posterior radicular columns. 

You perceive that by the above characters you may distin- 
guish fulgurating pains from a variety of others. For example, 
sciatica, or any neuralgia of the extremities, is characterized by 
the recurrence of pain along the nerve trunk, or along some of 
its branches — the patient can usually mark out with his fore- 
finger the distribution of the affected nerve. In rheumatism the 
pain is usually dull, deep-seated, affecting muscles or articula- 
tions ; it often involves numerous muscles or joints at one time, 
and is made worse by exertion. As regards the influence of 
weather, both fulgurating and rheumatic pains are apt to occur 
or increase in severity just before storms or sudden depressions 
of the barometer. The pain caused by vertebral caries, or by 
sj)inal tumors, is localized, and often can be referred to a spinal 
nerve trunk and its distribution. In poliomyelitis anterior, and 
in muscular atrophy there may occur severe pains, but they 
more resemble neuralgic pains as above described. 

2. The hyperesthesia observed in locomotor ataxia is not 
peculiar in kind, but in distribution. It consists in ordinary 
over-sensitiveness of the skin, tenderness if you please, limited 
to the patches of skin which are the seat of fulgurating pains. 
For example, if an oval spot about two inches in diameter on 
the anterior region of the thigh be the seat of stabbing pains 
for a few hours, it becomes exquisitely tender, and remains so 
for some time after the termination* of the paroxysm. In ordi- 
nary neuralgia the hyperesthesia is very different; we find a 
number of tender "points," not patches, some at the places 
where the nerve trunk becomes accessible to pressure, others 
where its branches approach a cutaneous distribution; there 
are nearly always two or more points in a neuralgic dis- 
trict. 

3. Anesthesia occurs in two ways in locomotor ataxia. At 



PROGRESSIVE LOCOMOTOR ATAXIA. 357 

an early period it is claimed that careful observation will dis- 
cover limited, and usually laterally symmetrical patches of skin 
which are partially or wholly devoid of sensibility. Possibly 
these patches represent regions where fulgurating pains have 
been repeatedly experienced. Later in the disease a progressive 
impairment of sensibility is developed in the feet, and ascends ; 
it may ultimately become complete throughout the lower (and 
upper) extremities. The chief peculiarities of this anaesthesia 
are, the predominance of analgesia or failure to perceive painful 
impressions, and retardation in the transmission of what impres- 
sions are perceived. This retardation I have often found, and 
have known an interval of more than one minute to occur be- 
tween the moment of pricking a patient's foot, and that of his 
saying that he felt it. Intervals of ten or twenty seconds are 
frequently found. I intend saying more of this anaesthesia when 
I come to speak of differential diagnosis. 

4 Ataxia of movement, a variety of inco-ordination, is justly 
held to be a most valuable symptom of progressive locomotor 
ataxia. Yet it is by no means pathognomonic as the disease 
(or lesion) may exist and the patient be incurable without a trace 
of ataxia being present ; and conversely, ataxia may be exhibited 
by patients who have not systematic sclerosis of the posterior 
columns. An exact delineation of ataxia seems to me as im- 
portant to attempt as that of fulgurating pains. By ataxia I 
understand a disorder in voluntary movement caused by want of 
harmony in the action of antagonistic muscles. The result is, 
that in doing a willed act, as walking, or putting the index finger 
on a given spot, there occur certain oscillations of the member 
used, which oscillations are the result of inharmonious auto- 
matic action of various muscular groups, extensors, flexors, ab- 
ductors, and adductors. In the lower extremities the extensor 
and abductor muscles usually predominate, hence the jerky, 
stamping walk of tabetic patients. Several peculiarities are 
worth noting. Ataxic movements are not observed while at 
rest ; they become evident when volitional acts are attempted. 
In chorea we have a form of inco-ordination in which various 
muscular groups contract involuntarily and at irregular times, 
but as much when the patient tries to keep still as at any time. 
Besides, in chorea, it cannot be said that antagonistic groups of 
muscles are affected, as the muscular contractions attack any 
and all muscles in the most capricious manner. Again, ataxic 



358 PROGRESSIVE LOCOMOTOR ATAXIA. 

movements are not rhythmical, which serVes to distinguish them 
from the movements observed in paralysis agitans. 

The presence of ataxia may be determined by the following 
methods of examination : When the patient is sitting or lying 
quietly no disorder is visible. On bidding him try to walk, if 
still able to stand, he starts off with his feet thrown outward and 
forward in a very exaggerated manner, and the heel is brought 
down forcibly. At the same time he staggers or oscillates like 
a drunken man, but this is not from ataxia. If the patient be 
unable to stand alone, upon being supported by a person on 
either side he will make the same punchinello-like movements 
of the legs in lieu of regular walking movements. In both de- 
grees of disability the extent of irregular movements is much 
increased if the patient's eyes be closed. If the patient be placed 
upon a couch and told to extend and abduct one of his legs so 
as to bring his great toe against the observer's forefinger, large 
oscillations will occur, and the attempt may wholly fail. Again 
in trying to do this, or in simply trying to raise the leg, such 
enormous extensor and abductor action may take place as to 
cause the limb to strike persons standing by the bed. While 
recumbent, if the patient's eyes be closed and he be told to place 
the heel of one foot upon the patella of the opposite leg, he will 
do it only after great aberrations, or wholly fail. 

If we suspect ataxia in the upper extremities we bid the 
patient place the end of his forefinger upon a small object, such 
as our own forefinger, or the end of his nose. If there be marked 
ataxia the object will only be reached after a number of misses 
or oscillations of the whole forearm and hand.. If he try to 
touch his own nose he may only succeed after having poked his 
finger into his mouth or eyes, or upon the cheek. Upon attempt- 
ing the same action with eyes closed the difficulty is greatly 
increased, and may actually be insuperable. All actions requir- 
ing co-ordination, as eating, writing, dressing, etc., become dif- 
ficult or impossible. In all this disorder we observe no tremor 
or choreic jerks. 

Mere muscular strength is nearly or quite preserved in arms 
and legs. 

Paralysis of various ocular muscles requires no description. 
Let it suffice to say that the third nerve is the one usually 
affected, though the abducens and patheticus are also paralyzed 
in some patients. The importance of the symptom lies in its 



PROGRESSIVE LOCOMOTOR ATAXIA. 359 

frequency, and its accompanying or even preceding the fulgurat- 
ing pains of the first stage of the disease. So true is this that a 
good many patients first consult an oculist for some trouble 
about the eye, and are by him referred to neurologists. 

II. Let us now pass on to the diagnosis of progressive loco- 
motor ataxia in its three generally recognized stages : 

(a) The first stage of the disease may well be designated, the 
stage of fulgurating pains. In order of frequency and impor- 
tance these are the symptoms which characterize it : 

Fulgurating pains. 

Localized hyperesthesia. 

Diplopia from strabismus. 

Ptosis from palsy of third nerve. 

Small pupils. 

Unequal pupils. 

Numbness and slight anaesthesia of feet. 

Sexual excitement. 

Seminal emissions. 

Paresis of the bladder. 

Diminished tendon reflex (tested at the knee). 

Impaired sight from atrophy of optic nerves). 

Slight arthropathies. 

Localized anaesthesia. 

Absence of paralysis or ataxia in the limbs. 

General health excellent. 

Of this long list only the fulgurating pains and ocular paralyses 
are of great importance, the former only are absolutely indis- 
pensable to the diagnosis. In some cases, for months and even 
years, no symptoms are present except fulgurating pains, and I 
think that from them alone, if we deal with an ordinarily intelli- 
gent patient, the diagnosis ought to be made. How many men 
have come to me with the story that during years of pain pre- 
ceding any disorder in movement, their family physician had 
told them, "Oh, its nothing but rheumatism." 

Very small pupils with even rare fulgurating pains make up 
quite a clear symptom-group ; and if to these we have added in 
a few months ptosis or internal strabismus, the case is very 
positively one of sclerosis of the posterior columns. Once in a 
great while we meet with the early combination of atrophy of the 



360 PROGRESSIVE LOCOMOTOR ATAXIA. 

optic nerves and fulgurating pains. I have seen examples of 
this unusual early stage. 

The following histories illustrate the first or neuralgic stage 
of sclerosis of the posterior column. 

Case I. Prolonged first stage. Male, aged 57 years ; an artist. Comes 
for advice about a "neuralgia " of long standing. For twenty-seven years has 
had severe pains in his lower, and since two or three years also in the upper 
extremities. Patient describes these pains as sudden, sharp, teasing, some- 
times of atrocious severity, occurring in spots or patches of round or oblong 
shape. These pains recur in one spot for some time, varying from a few min- 
utes to hours and days. In the course of these many years has had foci of pain 
in nearly every part of the lower extremities, more especially near the knees 
and ankles. In the last few years the intervals between j)aroxysms have 
become shorter, and the pains have grown more severe. There is now mydri- 
asis of the right eye, a condition which has existed thirty years, without 
diplopia. A mere trace of numbness has made its appearance in the legs, 
detected only at times by rubbing the skin. Painful spots are hypersesthetic 
during and after jDaroxysms. In the last few years urine slowly passed. Floor 
or ground feels normal under feet ; no difficulty in walking. Examination 
shows dilatation of right pupil; no diplopia, or changes in the optic nerves; 
no ataxia of upper or lower extremities ; very slight staggering when jDatient 
attempts to stand with eyes closed. The soles of the feet show a trace of an- 
aesthesia to ansesthesiometer. Reflex from ligamentum patellae lost ; no paresis. 
I am disposed to believe that this is the longest first stage of posterior spinal 
sclerosis on record. 

Case II. Prolonged first stage : arthropathies. Male, aged 32 years. Sent 
to my clinic by Dr. C. Williams. Characteristic pains in lower extremities 
for twelve years; spots of pain hyperaesthetic at time of attack. Slight numb- 
ness of feet; swelling of both knees in last two years; no difficulty in loco- 
motion. Examination shows moderate anaesthesia and analgesia in feet and 
legs nearly to knees; absence of knee tendon-reflex; double chronic arthri- 
tis of knee-joints with crepitations. Careful testing with eyes open or closed 
reveals no ataxia or staggering. 

In the vast majority of cases, as exemplified in the succeeding 
cases, the duration of the first stage is from one to four years. 

(b) The beginning of the second stage is characterized by the 
appearance of ataxic movements amid a large number of 
other symptoms. This may be called the ataxic stage. The 
chief symptoms are, in order of importance : 

Ataxic movements. 
Fulgurating pains. 
Localized hyperesthesia. 



PROGRESSIVE LOCOMOTOR ATAXIA. 361 

Ocular paralyses. 

Numbness and other dysesthesias. 

Anaesthesia. 

Staggering with closed eyes. 

Failure of sexual power. 

Absence of tendon-reflex. 

Rectal and vesical paresis. 

Gastric crises. 

Laryngeal " 

Vesical " 

Severe arthropathies. 

Amaurosis. 

Complicating common transverse myelitis. 

Spinal congestion. 

Paralytic dementia. 

Vesical catarrh. 

Preservation of mere muscular force. 

The exact grouping of the above symptoms at a given period 
varies infinitely in a series of cases. The all-important symj)- 
tom is ataxia. Yet ataxia without some of the above accompani- 
ments, notably without fulgurating pains, does not indicate sys- 
tematic sclerosis of the -posterior columns of the spinal cord, 
though it may mean that there is some disease of these columns, 
as, e. g., in* disseminated nodular sclerosis, no diphtheritic 
ataxia, etc. As regards the distribution of the ataxia, it is para- 
plegic in the vast majority of cases for all time, or for a long 
period. The upper extremities may be affected very severely 
while the patient is able to stand and take a few steps with the 
help of a cane, whereas in other cases the patient may die after 
having been many years bedridden without any extension above 
the waist taking place. 

The following are abbreviated histories of patients first seen in 
the second or ataxic stage of posterior spinal sclerosis. They 
illustrate the varied grouping of symptoms. 

Case III. First stage passing into the second. Male, aged 35 years. 
During the autumn of 1877, and since, has had moderately severe fulgurating 
pains in thighs, legs and feet. These are short, sharp, darting pains recur- 
ring in one spot for minutes or hours; the last paroxysm was upon the left 
instep and lasted twenty-four hours. During the spring and summer has 
thought that his eyes were growing weaker. Numbness has appeared in the 



362 PROGRESSIVE LOCOMOTOR ATAXIA. 

sole of both feet only in the last two weeks. Once or twice urine has escaped 
involuntarily. No diplopia, or impairment of vision. Patient standing with 
closed eyes oscillates a little ; his walk is a little stamping but not clearly 
ataxic. On the soles of the feet the sesthesiorneter shows slight anaesthesia ; 
pricking and touching are well felt. No reflex action from sole or ligamen- 
tum patella?. Strength at knee-joints, and grasp normal. Is generally weak 
and anaemic. 

In this case the first stage is about to pass into the second, or ataxic stage, 
after having lasted only about a year. 

Case IV. Developed second stage with ocular paresis. Male, aged forty- 
four years. Was well until the summer of 1876, when there occurred dizzi- 
ness and a tendency to go one-sided in walking. In the course of the next 
few months legs became weak but not numb, and in the summer of 1877, 
eyes became affected. Patient denies having had pains, but says that he has 
"rheumatism," and proceeds to describe regular fulgurating pains in various 
spots in the lower extremities ; shooting pains in one spot for hours or days 
These spots were hyperaesthetic. Has had such pains for four years. "When he 
consulted an oculist in summer of 1877, had diplopia, which has continued. 
For months has staggered when closing eyes (or when washing face) ; and 
feet have also been numb. It seems to the patient as if he were walking on cotton 
or india-rubber. No vesical symptoms; no symptoms in hands. Examination 
shows slight diplopia when looking outward to the right (paresis of right 
abducens), upper extremities strong and well co-ordinated. The walk is 
highly characteristic; the feet are kept apart, body swaying, legs jerked 
forward and outward, and heel brought sharply down at each step. Closing 
eyes makes standing impossible; looking up at ceiling aggravates walk. 
Soles of feet are much anaesthetic; sensations blunted and retarded. Reflex 
from soles abnormally great ; no tendon-reflex at knees. 

Case V. Fully developed second stage ; ocular symptoms, gastric crises. 
A female, aged fifty-two years, observed in the Presbyterian Hospital, Janu- 
ary, 1873. Admitted to the hospital on November 16th, 1872; gave the fol- 
lowing history : eighteen months previously had a first attack of severe 
vomiting, recurring every two or three hours, and extending over a period to 
thirty-six hours. Similar seizures recurred almost punctually every three 
months until last March. About ten months ago, after the third attack, she 
experienced sharp, shooting pains in her lower extremities from the hips 
down, continuing more or less actively for about three weeks. Although pa- 
tient was weak, yet she could walk well enough at that time, but not long 
afterward legs became feeble. Last spring, and since, the vomiting recurred 
more frequently, less violently, and irregularly. Two months ago (Septem- 
ber, 1872), she noticed that the lid of the left eye could not be fully raised. 
Just previous to this she had experienced shooting pains in the upper ex- 
tremities; pains just like those which had occurred in the lower extremities. 
The pains in the arms lasted about two weeks. From time of admission to 
January 1st, 1873, patient was treated by Dr. Wynkoop for nausea and fre- 
quent vomiting. On taking the service I examined Miss L., and determined 
the presenee of the following sjonptoms. There is ptosis on the left side, the 
pupil is a little dilated, and there is some external strabismus. Does not con- 



PROGRESSIVE LOCOMOTOR ATAXIA. 363 

verge well with right eye. Slight anaesthesia of the second and third 
branches of the trigeminus, (side not stated). Grasp of hand good; with 
eyes closed patient has difficulty in placing forefinger on end of nose, i.e., 
there is ataxia of the upper extremities ; more on the left side. Slight tactile 
anaesthesia of fingers and hands. Lower extremities are not, strictly speak- 
ing, paretic. In recumbent posture slight inco-ordination of legs. Later the 
vomiting was controlled ; hysterical symptoms of various kinds set in (so 
marked as to lead some of the medical staff to doubt the correctness of my 
diagnosis*), and, finally, on April 14th, the patient died suddenly of cerebellar 
haemorrhage. A post-mortem examination, supplemented by microscopic 
study of specimens, showed that the posterior columns of the spinal cord 
were extensively sclerosed. 

(c) The third stage may be said to begin when the anaesthesia 
and ataxia are so great as to render the patient perfectly 
unable to stand, or to " use his legs," as he terms it. This 
might aptly be called the pseudo-paralytic stage. 

In this terminal period we may have any of the following 
symptoms in various groupings, or even all of them : 
Fulgurating pains. 
Ataxic movements. 
Absolute anaesthesia. 
Loss of sexual power. 
Rectal and vesical paresis. 
Paralysis of ocular muscles. 
Amaurosis. 
Deafness. 
Various " crises." 
Severe arthropathies. 

Disorganization of large joints without pain. 
Seeming paralysis of the extremities from anaesthesia, 

(and loss of muscular sense ?). 
Dementia. 

Mere muscular power probably preserved. Electro-muscular 
contractibility is preserved. Reflex movements reduced or 
abolished. 

As complications : 

Cystitis and pyelo-nephritis. 
Pulmonary phthisis. 

* See page 180 ; also Archives of Ekctrology and Neurology, N. Y., May, 

1875. 



364 PROGRESSIVE LOCOMOTOR ATAXIA. 

Muscular atrophy. 
Transverse myelitis, etc. 

What is remarkable and characteristic in such cases is that 
the helpless patient whose legs fly about in the wildest manner 
when he attempts a voluntary movement, or, who, because of 
absolute anesthesia knows not how to guide his movements, 
can, for a few moments, show great strength of resistance to 
flexion at the knee-joint, or a nearly normal grasping power in 
his hands. In some cases, however, the patient is so completely 
isolated from his extremities by anaesthesia, so ignorant of their 
existence and whereabouts, that he can not move them. Yet, 
post-mortem evidence shows that the direct motor tract from the 
brain to the muscles is intact, and reasoning leads to the conclu- 
sion that there is at no time a true paralysis in the uncompli- 
cated disease. 

III. Differential diagnosis. This needs be made from a number 
of conditions. "When defining the fulgurating pains, character- 
istic of the first stage, I pointed out to you how they may be 
distinguished from purely neuralgic and rheumatic pains. The 
diseases which are often miscalled locomotor ataxia are the fol- 
lowing : 

1. Hysterical paraplegia of incomplete degree. The legs in 
this condition exhibit extreme anaesthesia, and if the patient be 
told to stand and then close her eyes she will oscillate and fall 
if not supported. Tested in the recumbent posture or by walk- 
ing no ataxia can be discovered, and the history of the case does 
not reveal the previous occurrence of fulgurating pains. 

2. Diphtheritic ataxia. In 1864, Prof. Jaccoud, of Paris, called 
attention to the occurrence of ataxia movements in certain 
patients who were said to have diphtheritic paralysis. I saw a 
remarkable case of this sort last winter in an adult who was sup- 
posed to have locomotor ataxia. He walked precisely like a 
tabetic patient, jerking his legs outward and forward, bringing 
his heel down. But in such a case we can make out an acute 
development ; and if the eyes are affected it is in a very different 
way from that seen in locomotor ataxia ; in diphtheritic cases 
the ciliary muscle alone is paralyzed, causing loss of accommo- 
dation and wide pupils. Negatively we fail to get an account of 
fulgurating pains, anaesthesia of the feet, peculiar vesical symp- 
toms. My patient recovered in a few weeks. 



PROGRESSIVE LOCOMOTOR ATAXIA. 365 

3. Paralytic dementia. In this disease the walk sometimes 
becomes almost ataxic, or at any rate a good deal of stamping 
with the heel is observed. In a few cases also, minor fulgurat- 
ing pains occur. The distinction is founded upon the different 
grouping of symptoms and the unimportant nature of the pains. 
Dementia (gradual diminution of mental power), with more or 
less marked exalted notions, irregularity of the pupils, and 
tremulous, jerky speech are the prominent symptoms. Still it 
it must be borne in mind that there is a bona fide relationship 
between the two affections, shown in an ascending and a descend- 
ing manner. In the ascending form true locomotor ataxia ter- 
minates with symptoms of paralytic dementia — of this I have 
seen at least four cases. The descending form has been alluded 
to at the beginning of this section. In the former case the spinal 
symptoms are primary and most important ; in the latter the 
symptoms of dementia command our attention and govern the 
diagnosis. 

4. Disseminated nodular spinal sclerosis. In this rare disease 
we do observe ataxia ; but it is of a grosser and less symmetrical 
sort. One extremity alone may be affected. Fulgurating pains 
are absent, or if they have occurred, it is only in a special region ; 
there is true paralysis in many parts, and the paralytic ocular 
symptoms are wanting. Besides, if the disease (as is usual) 
invade the medulla and brain, there are superadded exceedingly 
characteristic symptoms, viz. : interrupted or syllabic speech, 
nystagmus, hallucinations and delusions. 

In the cerebral form of disseminated nodular sclerosis we 
have ataxic movements, or ataxic tremor, without marked par- 
alysis, but with cerebral symptoms, and without fulgurating 
pains, anaesthesia of the soles of the feet, sexual and vesical 
symptoms. 

5. Chronic, transverse or diffused myelitis. It must seem 
strange that this disease should be confounded with locomotor 
ataxia ; but such is the fact. I have had quite a number of 
supposed cases of sclerosis of the posterior columns brought to 
me here and to my office, and the physicians in charge of the 
cases seemed much astonished at my diagnosis. The mistake 
turns wholly upon the exaggerated notion which practitioners 
entertain of the value of the symptom staggering with closed 
eyes. Patients with myelitis have numb and anaesthetic feet 
and legs, and when they are made to stand with eyes closed 



366 PROGRESSIVE LOCOMOTOR ATAXIA. 

they oscillate and fall, just as do patients with hysterical para- 
plegia. 

I would now repeat for the hundredth time, that staggering 
or falling with closed eyes is present in many affections of the 
nervous system, central and peripheral, and that it is not char- 
acteristic of any one disease. It simply indicates, in most cases, 
that the feet are anaesthetic ; in a few instances it cannot be 
explained in this way, and may be due to the loss or impairment 
of that questionable form of sensibility, the muscular sense. 

Several years ago, in the early days of this clinic, I brought 
into the amphitheatre a healthy young man, whose soles had 
been frozen with ice and salt. He walked fairly well with his 
eyes open ; but when they were closed, he oscillated a great 
deal, and was in danger of falling. 

Finally, gentlemen, I would remark that the recorded cases of 
cure of locomotor ataxia will not stand the test of the methods 
of diagnosis detailed above ; and their publication has not led 
me to abandon the opinion, held by all authorities I believe, 
that sclerosis of the posterior columns is an incurable disease 
at the present time. 



KEPOBT ON ACONITIA IN THE TBEATMENT OF TEI- 
GEMINAL NEUBALGIA* m 

The annual meeting of the Therapeutical Society was held 
October 11th, 1878, Dr. J. E. Learning, President, in the chair. 

The Committee on Neurotics, through its Chairman, Dr. E. C. 
Seguin, presented the following report : 

Gentlemen : I have the honor to submit the following brief 
preliminary report on the efficacy of the aconitia of Duquesnel 
in trigeminal neuralgia. 

This matter was made a subject of study by the Committee 
on Neurotics early in this year, chiefly because of the wide cir- 
culation of Prof. Gubler's statement that aconitia was almost 
infallible in trigeminal neuralgia. His original article appeared 
in the Gazette Hebdomadaire for February 9th, 1877 ; and good 
abstracts were published m the American Journal of the Medical 
Sciences for April, and in the Practitioner (of London) for August, 
1877. In his Lecons de Tlierapentique, Paris, 1877, Prof. Gubler 
has already stated his belief that aconitia was destined to be a 
very valuable remedy. 

It may be interesting to recall the fact that, writing in 1874, 
Dr. H. C. Wood, of Philadelphia, in his Treatise on Therapeutics, 
had said that aconitia should never be exhibited internally. Drs. 
August and Theodore Husemann, in their admirable work, 
entitled Die Pflanzenstoffe (Berlin, 1871), gave a full account of the 
preparation, and the chemical and physiological properties of 
aconitia. They do not mention Duquesnel's preparation, though 
it was made in 1864. 

Aconitia was extracted from aconitum napellus by Geiger and 
Hesse in 1833. This aconitia was amorphous, and probably 
impure, as are also the preparations now furnished by druggists 
under the names of Merck's, Hottot's and Morson's aconitia. 
Of these the last is considered the purest and best. 

Duquesnel's aconitia in crystals, although discovered in 1864, 
has been in use, apparently, only for the last seven years — 
since the experimental researches of Grehaul and Duquesnel in 
* Reprinted from the New York Medical Journal, December, 1878. 



3o8 ACONITIA IN TRIGEMINAL NEURALGIA. 

1871. The only sample of Duquesnel's preparation in this city 
to my knowledge is that held by Dr. Neergaard, the dis- 
tinguished pharmacist. With the chemistry and pharmacy of 
aconitia we have little or nothing to do, but an epitome of its 
physiological effects may not be out of place. 

From Husemann's, Wood's and Gubler's accounts the follow- 
ing may be stated with reference to the effects of this powerful 
alkaloid upon the animal organism. 

It paralyzes the sensory nervous system at its peripheral ex- 
tremities, and (probably) at its perceptive centres. 

It paralyzes the heart directly, and by way of the vagus nerve. 
The pulse-rate is reduced. It lowers the arterial tension. It is 
doubtful if it affects the motor-nervous system directly. The 
subjective sensations of a patient who is fully under the influ- 
ence of aconite or aconitia are : Numbness and tingling of the 
skin and mucous membranes, especially in the hands and tongue, 
a sense of chilliness and faintness, and indefinable nervousness. 

The doses of aconitia vary very much, according to the prep- 
aration used and according to the idiosyncrasies of patients. 
In general terms the initial dose of all three kinds — Morson's, 
Hottot's and Duquesnel's — may be 0.0005 gramme given twice or 
thrice a day. Prof. Gubler states that the dose of amorphous 
aconitia may be gradually raised to 0.005 gramme. He states 
that Duquesnel's crystallized aconitia is much stronger, and that 
we must be more careful in dosing it. 

In my own practice I have used great caution in prescribing 
Duquesnel's aconitia. My formula (first used last winter) is as 
follows : 

IjL Aconitise (Duquesnel's), .006 

Glycerine se, 

Spts. vini reci, aa 4. 

Aq. menthse pip., ad 62. 

M. One teaspoon = about .00045. 

S. A teaspoonful two or three times a day on an empty 
stomach. 

In some cases I have used .008 or even .01 aconitia in the 
same formula, fn this combination the solvent is the alcohol. 
The effects of various doses of aconitia upon our patients will 
be stated in the remarks which follow the relation of the follow- 
ing cases observed by your committee : 



ACONITIA IN TRIGEMINAL NEURALGIA. 369 

Case 1. Observed by Dr. T. A. McBride. — A male, aged twenty-eight 
years, seen at the New York Hospital in March, 1878. Complains of right 
supra-orbital neuralgia, which has lasted three months. The pain was con- 
stant at first, but latterly it has been paroxysmal and very severe. In the past 
week paresis of the right third nerve has supervened ; patient has ptosis, 
dilatation of pupil, and external strabismus. On March 3d is ordered .0006 
Duquesnel's aconitia in solution three times a day. Contrary to positive 
directions, the man did not report to Dr. McBride for four days, and then 
stated that he had been almost entirely relieved of pain; he had taken the 
medicine as directed until the evening of April 1st, when he stopped because 
of relief, and of tingling in tongue and ends of fingers. No change in paresis 
of motor oculi. Ordered sulphate of strychnia .003 t. i. d. The patient 
came regularly to the hospital for two weeks, and during that period there 
was no recurrence of pain. 

Case II. — Male ; seen at the Manhattan Hospital by Dr. Seguin. An ex- 
treme case of epileptiform-trigeminal neuralgia, of two or three years' stand- 
ing. In 1877 had derived great relief from Thompson's solution of phos- 
phorus in full doses. Chief seat of pain is in supra-orbital branches of tri- 
geminus, but all of its filaments in the left face sympathize in the attack. Was 
given .0006 of Duquesnel's aconitia twice a day for several days, with effect 
of provoking severe tingling, but without relief to pain or reduction in fre- 
quency of seizures. Patient not traced. 

Case III. — Male, aged about thirty-five years. Seen at clinic for diseases 
of the nervous system, College of Physicians and Surgeons, February, 1877. 
Old neuralgia of right infra-orbital nerves; epileptiform in type. Aconitia 
in doses of .0006 two or three times a day gave only slight relief; not enough 
to encourage continued treatment. Patient not traced. 

Case IY. — The reporter himself, in March, 1878, while weak from a com- 
bination of causes, had trigeminal neuralgia, involving all branches of the 
nerve on the left side, lasting six days. After failure of Thompson's solution 
of phosphorus, I tried aconitia, and took only .0003. Two doses were taken, 
with seA'ere physiological effects. I felt much tingling in the fingers, legs, 
and tongue, had rigors, and was cold and faint. The only good effect was 
very slight and transient relief from severe pain. The attack was brought to 
a close by the extraction of a bad tooth in the upper jaw of the affected side. 

Case Y. — Reported by Dr. N. B. Emerson at a meeting of the committee, 
held April 27, 1878. — J. D., aged thirty-two years, printer, presented himself 
February 15, 1878, suffering with attacks of violent pain in the first and second 
divisions of the right trigeminus, accompanied by clonic spasm of the facial 
muscles attached to the angle of the mouth on the same side. The pain was 
lightning-like in the suddenness of its onset, and was of the most acute form, 
causing him at the time of the attack to writhe with agony, and press his 
hands against the painful cheek. The affected side of the face was extremely 
sensitive. The paroxysms were very frequent. He had been similarly affected 
eight months before, and successfully treated by me with phosphorus and 
cod-liver oil. Present attack has not lasted long. No syphilis. There were 
several decayed teeth in the jaw, but they were not sensitive, and, in my 
opinion, were not likely to be the cause of the affection. Quinine, phosphorus 
24 



370 ACONITIA IN TRIGEMINAL NEURALGIA. 

and cod-liver oil, and morphine, were unsuccessfully used. I then decided to 
use aconitia, after Gubler's plan, and ordered : 

1$. Aconitiae cryst., - - - - .01 

Spts. vini rect., - q. s. 

Aquse, q. s. - - - - ad 62.— 
M. 

The first preparation was used two days without effect. I then directed the 
patient to have the prescription filled by Mr. Neergaard. At once .0006 pro- 
duced entire relief of pain, followed by numbness of the mouth, tongue, and 
face, with peculiar symptoms in the periphery. On the recurrence of pain 
the following day, .001 was taken with less physiological effect, and less 
relief. On the third day, two doses of .001 each were taken night and morn- 
ing, the terrible pain being relieved only after the second dose. Finally, 
after a dose of .0013 the pain remained entirely absent for eight days, and 
then returned with severity. 

Cask VI. — Observed by Dr. Seguin at the College of Physicians and Sur- 
geons. — Mrs. A. D., aged fifty-seven ; was first seen at clinic for diseases of 
the nervous system in the autumn of 1874. She gave the following history. 
In 1870 had trouble with the teeth in the right lower jaw, "caught cold in 
the gums," and present pain began. It occurred in paroxysms of sharp, 
severe pains in the right lower jaw, right half of tongue, and right half of 
lower lip. She suffered with no intermission up to the time when Dr. D. M. 
Stimson sent her to the college. The medicinal treatment which I then ad- 
vised had no more effect on the neuralgia than other modes which had been 
tried, including extraction of the teeth. 

In the succeeding summer, 1875 # Mrs. D. again came to see me, representing 
herself as under no physician's care. I accordingly took charge of her, and 
excised at least 6. mm. of her iuframaxillary nerve, by the intra-buccal 
method, also known as Lizars's. This was followed by absolute cessation 
of all pain in lip, tongue, and jaw, and by anaesthesia of the right half of 
the lower lip. 

In a few weeks, patient thinks three or four, some return of sensibility 
occurred in the anaesthetic district, and has increased until now even delicate 
tests reveal no anaesthesia. No pain recurred until the early spring of 1877, 
a period of twenty months. In April, 1877, patient's husband died, and she 
sat a long time near the ice-box in which his body was preserved. Immedi- 
ately had a return of neuralgic pain in the same regions, viz., tongue, gum, 
and lower lip of right side. The pain was again sharp and paroxysmal. 
She suffered greatly until late in the autumn of 1877, when spontaneous 
relief took place, and she had pain only at intervals during the whole winter. 
The only medicine which she took during this time was cod-liver oil. She 
had no powerful drugs. In the spring and early summer of this year she 
had as frequent and as severe attacks of pain as at any time; many par- 
oxysms each day, attacks epileptiform in suddenness of appearance and in 
severity. She presented herself at the clinic for diseases of the nervous sys- 
tem for the third time, on July 13, 1878, and the following notes from the 
clinic case-book embrace her history since that date : 



ACONITIA IN TRIGEMINAL NEURALGIA. 371 

July 15th. — The pain begins in the gum of the right lower jaw, then darts 
into the right half of tongue along its whole length, especially in its anterior 
portion ; it also affects the right half of the lower lip. She has no pain in 
the upper jaw or in the distribution of first branch of trigeminus, but it 
should be stated that she has a good deal of j>ain, also neuralgic in character, 
in the right side of the head behind the ear, the right side of the neck, and 
right shoulder. From almost the commencement of her illness, more or less 
of this pain has existed, varying greatly at times, but not annoying so much 
by far as the maxillary neuralgia. The paroxysms of pain in the jaw and 
tongue came on every few minutes. Once in a while, the patient adds, when 
the pain is greatest in the above-described region, a little of it shows itself in 
the gum of the right upper jaw. Is ordered a tonic mixture. 

July 20th. — Is better, generally, than last week. Ordered extract gelsemini 
fid., five drops t. i. d., the dose to be increased by one drop each day. 

July 27th. — Pain relieved by the gelseminum, seven drops of which pro- 
duced queer sensations and double vision. In the last few days has taken 
only six drops t. i. d. Ordered five drops twice a day and ten drops at bed- 
time. 

August 3d. — No marked benefit from above treatment, although much dis- 
tress was produced by the doses taken. Ordered .00045 of Duquesnel's 
aconitia in solution t. i. d. 

August 10th. — On the 7th reported at my office, and as the above doses had 
produced no effect I directed her to take .0006 t. i. d. on an empty stomach. 
To-day (three days after beginning the larger doses) she is free from neuralgic 
pain, though some soreness of the parts remains. After each dose of .0006 
had some tingling in extremities and face. Treatment to be continued. 

August 31st. — Has had no paroxysm of pain since beginning the .0006 dose. 
Has only noticed an occasional soreness in the tongue, provoked especially by 
acids. Can eat with comfort, whereas three weeks ago attempts at mastica- 
tion caused agony. States that effects of one dose of aconitia consist in ting- 
ling in the whole body, most marked in the toes and fingers, and in peculiar 
chilly sensations. 

The pain in the neck and shoulders is not wholly relieved. Complains of 
much sweating at night. To take for two or three days one .60 dose of sul- 
phate of quinia at bedtime. The aconitia to be omitted, and Fowler's solu- 
tion to be taken instead, in doses of three drops after meals, gradually increased. 

September 14th. — Has remained perfectly free from facial neuralgia, and has 
only moderate pain in side of neck, right shoulder, and upper arm. Has 
taken ten drops of Fowler's solution without unpleasant effects; sweating 
arrested. Ordered to cease taking arsenic, and to use 4.cc. of Thompson's 
solution of phosphorus (=.003 of phosphorus) night and morning. 

September 21st. — Had slight return of pain in right lower jaw and tongue 
on September 18th and 19th, arrested by a few doses of aconitia. To-day is 
perfectly well, except that right side of neck and arm is painful. 

October 11th. — Has had no return of neuralgia since last note, and neck has 
not been so painful. States that she has more or less pain in the whole right 
side, from behind the ear to arms and down lower extremity to heel at times. 
With exception of slight neuralgic pains on September 18 and 19, has had no 



372 ACONITIA IN TRIGEMINAL NEURALGIA. 

recurrence of inferior maxillary or liugual neuralgia since August 7th, a period 
of sixty-five days. 

I append a case of another form of pain, viz., the severest fulgurating 
pains of sclerosis of the posterior columns, in illustration of the toleration 
of large doses of aconitia. 

Case VII.— Mr. B. , 57 years of age, has suffered from typical fulgurat- 
ing pains in the lower extremities for twenty-seven years.' He has as yet no 
trace of ataxia, and, the only other symptom of spinal disease present is 
mydriasis of the right eye. 

One of the favorite seats of these pains has been the internal aspect of the 

right leg, and in the last six weeks Mr. B has had innumerable paroxysms 

of cutting, tearing, and grinding pain in this region, sometimes causing ex- 
treme agony. Wishing to try aconitia for the relief of these pains, I gave 
him at first .00045 three times a day, and, not obtaining any relief or any 
physiological effects, gradually increased the dose to such a point that in 
forty-eight hours, ending October 4th, he consumed .01 without relief to 
pain, and with no physiological effect, except a transient and doubtful ting- 
ling in the finger-tips. I did not care to push the remedy farther. I should 
add that the prescription was filled at Neergaard's, and that I took pains to 
make inquiries as to possible errors iu its preparation. 

From the above cases the following conclusions may be justly 
drawn, I think : 

1. The susceptibility of individuals to Duquesnel's aconitia 
varies enormously ; one individual in the series having been 
severely affected by .0003, while another tolerated with no special 
symptoms .0008 every three hours. On the average, distinct 
physiological and therapeutical effects were obtained by giving 
.0006 three times a day. 

2. Out of six cases of severe trigeminal neuralgia, one, prob- 
ably a reflex neuralgia from a decayed tooth, was not at all 
benefited. 

Three cases, epileptiform in form, were slightly or only tem- 
porarily -relieved. Two cases were cured. One of these had 
existed for seven years, with an interruption of twenty months, 
procured by resection of the affected nerve. 

It would thus appear that while we cannot indorse Prof. Gub- 
ler's statement that Duquesnel's aconitia never fails, we must 
recognize in it one of the most powerful and best agents for 
relieving and curing trigeminal neuralgia. 

3. We do not as yet know the forms of trigeminal neuralgia 
which can be most influenced by aconitia. The three following 
cases have been reported to the committee since meeting of the 
society at which this report was read. 



ACONITIA IN TRIGEMINAL NEURALGIA. 373 

Case VIII. Observed by Dr. 0. B. Douglas. — Mrs. C. H. M., aged nine- 
teen, born in New York ; married; was, October 19th, attacked with severe 
neuralgic pain in left eye — extending to submaxillary and bregmatic regions 
— which continued increasing in severity for three days and nights, being 
much worse at night, till she could only walk the floor and cry from pain. 
On the fourth day I saw her, and ordered, commencing at 10 a.m., drop doses 
of tincture of aconite root, beginning with, four doses the first hour, two the 
second, and one each subsequent hour till relieved or physiological effects 
produced. The pain subsided, and she slept well the following night till 2 
a.m., when, with slight return of pain, she awoke, took two doses, and slept 
till morning, and has had no return of the trouble to this date (Oct. 25th). 

Last winter she suffered two weeks from a similar attack, and has been sub- 
ject to neuralgic pains at other times, usually a result of exposure to cold. 
In all fourteen doses were taken, but no physiological effects of the drug were 
observable. 

Case IX. Observed by Dr. A. H. Smith. — Mrs. R., aged forty-four years; 
married; seen October 13th. Had been suffering with severe pain in the face 
for four weeks, pain beginning in the right side, then passing to the left 
temporal and frontal region, and also affecting the left arm. It was aggra- 
vated to such an extent by the recumbent posture that the patient was unable 
to lie down. The night of the 12th was passed in extreme pain. Ordered 
the .00045 of Duquesnel's aconitia to be taken every four hours. Two doses 
were taken on the 13th with a slight degree of relief. On the 14th ordered 
the medicine to be taken every three hours. There was a decided abatement 
of the pain. At seven o'clock in the evening the patient experienced a numb 
and tingling sensation in the lips and tongue, and more or less over the whole 
right side, and especially in the fingers of the right hand. It icas not felt at 
all in the parts affected by the neuralgia. The sensation was so decided that 
the patient, although forewarned, was considerably alarmed. 

The night of the 14th was passed very comfortably, as was also the follow- 
ing day. During the evening of the 15th, however, the pain returned with 
great severity, but in the right instead of the left side. The medicine 
had been taken every three hours and a half; directed it. to be taken at in- 
tervals of three hours. On the 16th there were again decided numbness and 
tingling, affecting this time chiefly the left side, -the pain being chiefly in the 
right. The pain was greatly mitigated during the day, but returned every 
evening between seven and eight o'clock, lasting three to four hours. The 
19th and 20th, however, passed by without a paroxysm. After that there 
was a recurrence every alternate day at about 5 p.m., lasting four hours. On 
the 21st quinine was ordered; the aconitia continued. Did not see her again 
until to-day (26th). Quinine had produced nausea, and had not been effi- 
ciently taken. Paroxysms have continued regularly and with unabated 
severity. Physiological effects of aconitia limited to tingling in tongue and 
lips. During one day the dose was repeated every two hours. 

Case X. Observed by Dr. Seguin. — Male, aged thirty-nine. Epileptiform 
neuralgia on right side, involving all branches except lingual, for ten years. Suf- 
fering atrocious ; many paroxysms a day. The case is under treatment, and is 
not ready for report, but I may say that Duquesnel's aconitia, given in doses of 



374 



ACONITIA IN TRIGEMINAL NEURALGIA. 



.0006 three and four times a day, has produced physiological effects and 
diminished the severity of the disease. In the last week patient has had 
only one or two severe paroxysms a day, and few slight pains. The relief 
is so great that patient uses extravagant expressions of gratitude, "is in 
heaven," etc. This is the first treatment which has relieved him. At this 
date (October 27th) he is still under treatment, taking .0006 three times 
a day; iodide of potassium (no syphilis), and dialyzed iron. 

These cases do not alter, but only confirm the committee's conclusions, 
as expressed supra. 



A CONTRIBUTION TO THE MEDICINAL TKEATMENT 
OF CHEONIC TRIGEMINAL NEURALGIA* 

Having recently met with three cases of severe chronic neu- 
ralgia of the trigeminus which have been favorably influenced 
by the internal administration of medicines, I have requested 
the privilege of presenting a report upon them to the Society. 

Case I. — Epileptiform neuralgia of thirteen years' standing : cure. — J. "W., a 
farmer, aged 63 years, presented himself at my clinic for Diseases of the Ner- 
vous System on or about June 15, 1878, and gave the following history: Has 
suffered from neuralgia in the right side of the face for thirteen years. The 
first pain, slight and stinging, made its appearance near the external angular 
process of the frontal bone. There was a gradual increase in the frequency 
of the paroxysms, and in the severity of the pain, until the time of examina- 
tion. During three years has had almost constant pain, i.e., the paroxysms 
have been repeated every two or three minutes. There has been much pain at 
night, but the greatest suffering has always been experienced in the fore- 
noon. The seat of neuralgia has been the right malar region and the lower 
anterior temporal region. Paroxysms have been excited by the contact of 
clothing or of the finger; by talking or eating, and by pulling the hair on 
the lip and cheek. The pain has never been periodical. 

The patient's general health has always been good ; he has had two attacks 
of malarial fever: one when a boy, the last six years ago. When the attack 
began he was living in Marlboro, Ulster Co., N. Y., considered a healthy 
place. Has never had syphilis; has always been temperate. 

Attack witnessed at the clinic : A sharp and exceedingly severe pain appears 
in the region defined above, accompanied by injection of the cheek and eye, 
and the escape of tears. The paroxysm lasts several seconds, and returns 
every two or three minutes. Nitrite of amyl seems to mitigate the suffering. 
Examination of the affected and of adjacent parts is negative ; there are no 
anaesthesia or true tender points, or any exciting cause of pain within the 
mouth. The etiology of the affection is unknown. 

Treatment. — From June 17th to 21st, hypodermic injections of Squibb's 
chloroform were made daily through the mucous membrane of the cheek 
toward the malar region, from one to ten minims being used each time. In 
making these injections care was taken to avoid the point of exit of the infra- 
orbital nerve. The last injection was made near the supra-orbital nerve. 
These injections produced some smarting pain and secured relief for several 

* Read before the New York Neurological Society, Dec. 2, 1878. Reprinted 
from the N. Y. Medical Record, Jan. 4, 1879, Vol. XV. 



376 CHRONIC TRIGEMINAL NEURALGIA. 

hours each day, but did no more: the pain returning the next day as severely 
as before. Some bad effects were, however, produced, and these are worthy 
ol consideration because hypodermic injections of chloroform in the face 
are usually considered harmless. I observed in this case some swelling at 
the seat of injection, paresis of the lower facial muscles of the type pro- 
duced by lesions of the cerebral hemispheres: there was also marked numb- 
ness and slight anaesthesia in the skin of the cheek near the angle of the 
mouth, and over the eyebrow. The electro-muscular reactions remained 
normal, no abscess followed, and the paresis gradually passed away. I 
might add that similar unpleasant results ensued in another case in my prac- 
tice about a year ago. 

On June 26th, 27th, 2Mb. daily injections of Fowler's solution (diluted 
one-half i were made in the affected cheek through the mucous membrane 
without good or bad effects. 

From June 21st to 26th, I tried Thompson's solution of phosphorus, in 
doses of one teaspoonful (.003 of phosphorus' three and four times a day 
without marked benefit. 

Still, on the whole, at the end of June, the patient was somewhat improved, 
having severe paroxysms only from four to ten times a day ; though siight, 
sharp pains were still very frequent. 

About the end of June he was given iodide of potassium in gradually in- 
creasing doses of a saturated solution. He began with ten drops three times 
a day. and by an increase of live drops per day at each dose, he attained a 
maximum of ninety-live drops three times a day. Xo evident benefit resulted 
from this course, which was terminated on July 12th. 

On July 13th. was ordered five drops of the fluid extract of gelseminum 
four times a day. July loth. — Reports himself as very much relieved : no 
special symptoms have been produced by the drug: is directed to take eight 
drops four times daily. July 16th. — Yesterday had no paroxysm except while 
eating: there have been frequent but bearable "ticks" of pain in the vicinity 
of the right external angular process of the frontal bone. Is ordered to take 
ten drops four times a day. 

August 1st. — About this time, as the patient could no longer stay in town, 
and as I was unwilling to let him take gleseminum while away from observa- 
tion, the solution of iodide of potassium was again given in doses of sixty 
drops three times a day. 

August 10th. — Patient returns to town, and reports himself no better; lie 
has taken the medicine regularly, and has kept a journal of the attacks. The 
number of attacks per diem, usually excited by eating, etc.. have varied from 
four to eight. The iodide is suspended. The actual platinum cautery is 
gently applied over the right malar and temporal regions, and five drops of 
Fowler's solution are given in water three times a day. to be gradually in- 
creased. August 20th. the diary shows a decrease in the number and in the 
severity of the pains: only from three to five paroxysms a day: three yester- 
day. Has been cauterized three times. 

August 22d. — About this time the neuralgia ceased altogether, the dose of 
Fowler's solution being ten drops three times daily. 

September 22d. — Patient has had no pain since the last note — a period of 



CHRONIC TRIGEMINAL NEURALGIA. 377 

thirty-two days. Absolutely no pain has been felt, and the hyperesthesia has 
disappeared; patient can eat, talk, wash, or rub his face with impunity for 
the first time in many years. The paresis of the lower face, produced by the 
injections of chloroform, has nearly passed away, and there is no more numb- 
ness. Xo toxic effects have been caused by the arsenic; but. as he has taken 
ten drops so long, a change is made to Thompson's solution of phosphorus. 
one teaspoonful three times a day. 

On September 24th a few slight paroxysms occurred, and the patient, of 
his own accord, resumed the arsenical solution in full doses, and in a day or 
two the pains ceased, and they have not returned. 

Early in November this patient was shown at my clinic. He then asserted 
that he was perfectly well, and his healthy and cheerful aspect confirmed his 
statement. As he has not returned, I feel reasonably sure that the good result 
has been permanent. * 

Case II. — Epileptiform trigeminal neuralgia of ten years standing greatly re- 
lieved Ini treatment. — H. S.. aged 29 years, a janitor by occupation, consulted 
me on October 2. 1878, and gave the following history: Syphilis was denied. 
Previous to the development of the present affection he had been subject to 
occasional dull headaches. Ten years ago lie suddenly experienced a very 
severe sharp pain all through his head, "as if devils were at work there," 
lasting half an hour. There was no dizziness, or nausea, or faintness. or 
impairment of sight, or paralysis. For a period of six mouths he remained 
free from pain, and, indeed, was perfectly well: then a "dull, stupid pain" 
began over the right eye. extending from the supra-orbital notch inward to 
the nose, and down the side of the nose to the ala. This pain was paroxysmal, 
and worse in the day-time. Later the pain extended to the eyeball, and was 
exceedingly severe: the paroxysms recurring from ten to twelve times a day. 
In the course of two or three years, pain made its appearance in the right 
temple, worse at night. 

In the last few years the most pain has been on the top of the head, above 
the temple, and in front of the ear to the bregma. There has lately been an 
occasional and rare pain in the nose ; not much in the temple. During the 
past summer and since, there has been some occipital pain on both sides, 
more on the right. In the last year there has also been pain in both jaws, in 
the upper lip near the median line : none in the tongue. In the last four 
years vision has been dim. and glasses have not corrected this defect. Five 
years ago. while taking medicine, had temporary diplopia. At various times 
during this long illness has had "dizzy spells'' with varying frequency ; 
seldom in the last few months. Has had no symptoms in other parts of the 
body : memory is impaired ; the virile power quite lost. Had severe dyspepsia 
and vomiting three years ago. and has been costive during the whole period 
of the disease. The various painful regions are hypersesthetic. but not numb, 
and the tactile sensibility is perfectly preserved on both sides. There is no 
facial paralysis ; the right pupil is positively small, the left normal. After 
dilatation by atropine, the ophthalmoscope shows nothing abnormal in the 

* A letter from this patient's wife, received about December 10th, states that he 
remains well. 



378 CHRONIC TRIGEMINAL NEURALGIA. 

bottom of the eye. Hearing, smell, and taste are normal. The urine has 
been frequently examined by physicians and always found normal ; it is now 
free from albumen. Marked anaemia is present in the skin and mucous mem- 
branes ; has always been pale. 

The paroxysms of pain are the most terrible which I have ever witnessed ; 
the patient fairly writhing in his chair or falling to the floor in his agony. 
During the attack the right eye is very much injected and waters. 

The patient states that no medicine has ever relieved him, and he has tried 
a great many. I at once prescribed Duquesnel's crystallized aconitia, a 
remedy with which I had obtained remarkable results during the year. The 
prescription was : 

R. Aconitia} (Duquesnel's) * .008 

Spts. vini rect., 

Glycerinae, aa 4.cc. 

Aq. menthae pip. ad 62.ee. 

M. . 
S. — A teaspoonful three times a day between meals. 

I also gave him one teasj:>oonful of Wyeth's dialyzed iron every evening at 
bed-time. 

Oct. 3d. — Has severe paroxysms every day ; seven on October 3d, and nine 
yesterday. 

Oct. 11th. — Has only slight physiological effects (numbness) in the finger- 
tips ; from six to nine attacks each day. Now takes .0008 aconitiae three 
times a day. 

Oct. 14th. — On the 12th had twelve severe spells ; only two yesterday. 
He yesterday took, by mistake, 8.cc of aconitia solution, or .0015, twice, 
and two doses of4.ee, and this morning 8.cc. This is the equivalent of .000 
of aconitia in twenty-four hours. He is very nervous, feels as if electricity 
were passing through his body and limbs ; he " cannot contain himself." As 
this was a mistake, I directed him to resume the prescribed doses of O.cc ter 
die. The results of the mistake were, however, most fortunate ; improve- 
ment began from this strong impression of aconitia upon the system, as 
shown in the tabular record of paroxysms : 

Oct. 19th. — Excellent record ; since October 13th has had only from one 
to three severe attacks ; ordered to continue aconitia and to begin a saturated 
solution of iodide of potassium in five drop doses. 

Oct. 31st. — Continues to do well, i.e., has from one to two or three severe 
paroxysms daily, and a number of slight twinges. Feels numb and "very 
cold " from three doses of aconitia. Can't be warmed even by an overcoat ; 
general condition much improved ; physiognomy calm and contented. 
Besides aconitia, takes twenty-eight drops of solution of potash. 

Nov. 30th. — Improvement maintained. Passes some days without severe 
attacks, and a few with no pain at all. Plas done much of his work as 
janitor of late. The aconitia has lately (since 23d) been taken twice a day, 
and he has hardly any numbness. 

On Dec. 19.— Pills of arsenic .004, quinia .20, and belladonna, .02, were 



CHRONIC TRIGEMINAL NEURALGIA. 379 

substituted for the iodide of potassium. The iron is kept up at night, 4.cc. 
of dialyzed iron. 

Case III. Sec p. 370. 

It seems to me that three conclusions may legitimately be 
drawn from the above related cases : 

1. That there is a possibility of relief in most severe cases of 
epileptiform trigeminal neuralgia. The usually received opinion 
is that, in such cases, recourse must be had to operation upon 
deep branches of the nerve, excision of Meckel's ganglion, etc., 
and to the systematic use of morphia to make life endurable. 
After my experience with the above cases, I am disposed to urge 
a sufferer from trigeminal neuralgia to make a trial of medicinal 
treatment. 

2. The advantage of using medicines systematically. Not only 
should the doses of any one remedy be administered regularly 
and in progressively increasing doses, but several remedies may 
be used in succession, so as to profoundly affect the system. Of 
the medicines applicable for the treatment of neuralgia, the fol- 
lowing are those which I can recommend most highly : aconitia, 
arsenic, iodide of potassium, gelseminum, belladonna, quinia, 
morphia, galvanism, the actual cautery, Thompson's solution of 
phosphorus. 

3. In the treatment of chronic neuralgia and of many neuroses, 
it is necessary to obtain the physiological effects of the drug 
employed, in order to do good. This principle of heroic medi- 
cation is one which ensures success in seemingly desperate cases, 
and its execution requires the utmost watchfulness on the part 
of the physician, and intelligence and faithfulness on the part of 
the patient and his attendants. Many unpleasant consequences 
of such treatment may be avoided if we at first give very small 
doses of the remedy, and then make a very progressive increase. . 
The good effects of giving medicines to the production of phys- 
iological effects are illustrated in the above cases ; in the treat- 
ment of chorea by arsenic ; of malarial affections by quinia ; of 
spinal congestion and myelitis by belladonna ; of syphilitic 
disease by mercury and iodide of potassium, etc., etc. 

Inasmuch as the good effects noted in cases II. and 111. were 
obtained by the action of Duquesnel's aconitia, it may not be 
amiss to refer here to the conclusions of a report on aconitia 
recently made to the New York Therapeutical Society by its 
Committee on Neurotics. * 

* Vide, p. 367, also N. Y. Medical Journal, 1878, p. 621, Vol. 28. 



DEBMATITIS PEODUCED BY THEEE PEEPABATIONS 
OF OPIUM m THE SAME SUBJECT.* 

The following case, illustrating the unexpected results which 
may follow the moderate use of well known remedies, was of 
great interest to the Committee on Neurotics of the N. Y. Thera- 
peutical Society, and is perhaps worthy of record. The patient 
was a lady about fifty years of age, of nervous temperament, and 
of generally good health. "When I first saw her on September 
24th, 1878, she had been suffering for several months from mild 
melancholia ; her chief symptoms being sadness, delusions as 
to her wickedness, hopelessness of recovery through human 
agency, and insommia. On my proposing the opium treatment 
which is my main reliance in such cases, I was told that some 
time ago a very small dose of morphine had produced an erysi- 
pelatous eruption. Unwilling to give up my mainstay in treat- 
ment, I preferred to run the risk and prescribed a pill composed 
of extract of opium, .008 extract of cannabis indica, .015 and 
quinine, .12, to be taken three times a day. The next morning, 
after having taken three pills, Miss L. called and showed me upon 
her neck an erythematous patch almost encircling it, and which 
was the seat of extreme burning and itching. She stated that 
several such patches were on other parts of the body. The 
patches appeared red and felt hot; they presented neither 
papules or vesicles. This eruption exactly resembled, the 
patient said, the " erysipelas," which had on several occasions 
been caused by morphine and opium. It should be added that 
although the patient had no knowledge of my prescription, she 
positively expressed her belief that I had given her opium. On 
the third day the symptoms were aggravated. In addition to 
erythema of the neck, there was a distinctly erysipelatous con- 
dition of one upper eyelid; characterized by redness, oedema and 
tenderness. The opium was now (Sept. 26th,) discontinued, and 
in a few days the skin resumed its usual healthy appearance. 

The patient steadily improved in her mental condition, under 

* From the Archives of Medicine, Feb., 1879. 



TRAUMATIC MYELITIS ANTERIOR. 381 

the use of dilute nitro-muriatic acid and strychnia before meals, 
and of camphor and cannabis pills at bed-time. 

On November 11th, I ordered in place of the above pills, others 
composed of cannabis, .06, camphor, .12, codeia, .03, aloes, .03 ; 
one to be taken at night. On the very next morning, (Nov. 12,) 
the unfortunate lady exhibited an erythma on neck, shoulders 
and body, the left eyelid was red and a little swollen. She was 
told to resume pills without codeia, and very soon all trace of 
the cutaneous affection disappeared. 



MYELITIS OF THE ANTEKIOE HOENS OF TKAUMATIC 

OKIGIN.* 

F. M., a carpenter, twenty-seven years of age, presented him- 
self at my clinic for Diseases of the Nervous System, on Septem- 
ber 20th, 1878, and gave the following history. On the sixth of 
April last he fell from the fifth story of a building, and dropped 
obliquely upon the sidewalk and curbstone, striking his hip and 
side. He did not lose consciousness, and there was no marked 
external injury. He immediately experienced partial paralysis 
of both lower extremities, and of the left upper extremity. In 
four weeks recovered the use of his arm. In six weeks later he 
began to improve in his lower limbs, and by July 20th, could 
walk without crutches. At no time was there any loss of sensa- 
tion, though there was a degree of numbness and tingling of the 
paralyzed parts. Had no pains, cramps, or jerking of these 
parts, but he well describes epileptoid trepidation. Urine was 
retained (catheter used) for three weeks after accident, rectum 
unaffected ; never incontinence of urine. Since July has re- 
gained his normal state except a peculiar disability in his legs, 
and burning in the toes of both feet, which perspire freely. 

Examination : Patient free from symptoms above knees ; below 
knees has atrophic paralysis of the anterior tibial group of 
muscles on both sides. In walking, the feet are brought to the 
ground in a slapping or flapping manner. Posterior tibial and 
peroneal muscles normal. No tendon-reflex at knees, but foot- 
phenomenon can be slightly produced on both sides. Sensibility 
normal. Electrical reactions ; no faradic or galvanic reaction in 

* From the Archives of Medicine, Feb., 1879. 



382 TRAUMATIC MYELITIS ANTERIOR. 

anterior tibial nerve ; no faradic reaction in anterior tibial 
muscles ; galvanism produces slow contractions in the paralyzed 
muscles with the formula Ka CC = An CC. Up to present 
time (January 10th, 1879), M. has been treated with galvanism 
to the legs, ergot and iodide of potassium. Although several 
accidental causes have interrupted the treatment, marked im- 
provement has taken place. Some voluntary power has returned 
in all the muscles of the left anterior tibial group, and in the 
tibialis anticus of the right side. 

It would seem as if a sudden hyperemia of the cord had been 
produced by the fall, with hemorrhage or myelitis in the lumbar 
region limited to a small part of the anteridr horns, seriously 
injuring those ganglion cells which give origin to the nerve fibres 
innervating the anterior tibial regions. One case of traumatic 
infantile paralysis (lesion of the anterior horns), by Dr. Allbutt, 
(Lancet, 1870, II., p. 84), and another in the adult by Prof. Leyden, 
(ArcMv fur Psychiatrie und Nervenkrankheiten, vi. p. 271), have 
been placed on record. A number of cases of traumatic spinal 
paralysis in. the course of which muscular atrophy appeared, are 
also recorded by Ollivier, Gull, and Erichsen. 



THE PKESENT ASPECT OF THE QUESTION OF TE- 
TANOID PAKAPLEGIA.* 

Synonyms, Sjmstische Spinalparalyse, Ekb ; Tabes dorsal spasmodique, Charcot. 

In the last five years a new symptom-group, indicating disease 
of the spinal cord has been independently observed and described 
by several physicians. 

In 1873 I published under the somewhat unfortunate name of 
" tetanoid pseudo-paraplegia," five peculiar cases which I had 
studied in the three preceding years. t I then defined this 
" peculiar paraplegiform affection " as follows : " This form of 
false paraplegia (using the word as implying the existence of 
paresis or akinesis in the lower limbs) is characterized by im- 
pairment of the functions of the lower extremities, when the 
patient is in the erect posture, without any loss of power in 
these parts. Further analysis shows that the seeming paraplegia 
is dependent upon tonic spasm of the . muscles of the lower 
limbs. As negative characters we have absence of the symptom 
ataxia, and often, also, preservation of sensibility." 

Possibly I may be pardoned for claiming that this paragraph 
contains, with some errors, the essence of the symtomatology of 
the condition now under consideration. 

In May, 1875, Prof. W. Erb, of Heidelberg, who had seen my 
essay, read a paper, before the Association of Physicians for 
Nervous and Mental Diseases held at Heppenheim,J upon a 
condition of spasmodic spinal paralysis, in which he describes 
cases of paresis of the lower limb complicated with stiffness 
and even contracture of the lower limbs, without anaesthesia. In 
this paper he gave a description of the " spastic walk," in terms 
not very different from those I used in 1873 ; substantially the 
same essay was reproduced shortly afterward in the Berliner 

* Reprinted from Archives of Medicine, February, 1879. 

f Description of a peculiar paraplegiform affection. See Vol. I., p 127; also 
Archives of Scientific and Practical Medicine, February, 1873, New York, p. 101. 

X W. Erb. Ueber einen wenig bekannten spinalen Symptomencomplex. Zeit- 
schrift fur Psychiatrie, Band XXXII., 1875. Also in Berliner klinische Wochen- 
schrift, 1875, Band 12, p. 357. 



384 PRESENT ASPECT OF TETANOID PARAPLEGIA. 

Klinisclie Woclienschrift, and since, the condition of spastic spinal 
paralysis lias had a place in nosology. It has not been noticed 
in the various articles upon tetanoid paraplegia that, in his 
Treatise on the Diseases of the Nervous System * (preface dated 
March 10th, 1876), Prof. Hammond described this rigid paraly- 
sis, and referred to Tiirck's and Charcot's pathological observa- 
tions in cases of sclerosis of the lateral columns. He accepts the 
symptom-group as a natural one. 

In 1876, Prof. Charcot t of Paris, who had observed the symp- 
toms before becoming acquainted with Erb's work, delivered one 
or more clinical lectures upon the subject, calling the affection 
Tabes dorsal spasmodique. 

In the same year Charcot's views were reiterated by one of 
his pupils, J. Betous, in his inaugural dissertation.^ 

In both these publications the opinion is expressed that the 
symptoms which I prefer to designate as tetanoid paraplegia, 
are caused by primary disease of the lateral columns of the 
spinal cord, a form of sclerosis, either of tlie disseminated or of 
the systematic type. 

This propositibn of Charcot's was based upon an autopsy in a 
case of so-called hysterical contracture, in which he had found§ 
symmetrical sclerosis of the lateral columns, and upon the results 
of two autopsies by Ludwig Tiirck || in 1856. Unfortunately, the 
notes of these cases are not of such a nature as to afford us any 
aid in the study of the symptom-group under consideration (Ebb). 

In 1877, Prof. Erb wrote a more elaborate essay! upon the 
symptom-group in question, which he then designated by the 
term spastic spinal paralysis, and which he, following Charcot, 
believed to be due to primary sclerosis of the lateral columns of 
the spinal cord. More recently still, in Vol. XIII. of the Ameri- 
can edition of Ziemssen's Cyclopaedia, he has reiterated his views 
unchanged. 

* A treatise on the diseases of the nervous system. Sixth Edition. New York, 
1876, p. 569. 

f Lecons sur les maladies du systeme nerveux. T. II., 15me Lecon, p. 275, 
2me Edition, Paris, 1877. 

X Etude sur le tabes dorsal spasmodique. These de Paris, 1876. 

§ Gazette Rebdomadaire, 1865, p. 109. 

| Ueber primare Degeneration einzelner Kiickenmarksstrange. SitzungsbericM 
der k. k. AJcademie zu Wien, 1816. 

% Ueber die spastiche Spinalparalyse (Tabes dorsal spasmodique, Charcot). 
Virchow's Archiv fur patliologishe Anatomic Band LXX , 1877. Idem, Zi ems- 
sen's Cyclopedia of Practice of Medicine, American Edition, Vol. XIII., p. 620. 



PRESENT ASPECT OF TETANOID PARAPLEGIA. 385 

Since Erb's and Charcot's first publications, numerous contri- 
butions to the literature of the subject have appeared, among 
which I may name 0. Bergeiy* F. Eichter,t Seeligmuller,^ K. 
Schultz,§ M. Kosenthal,! Stofella,T and L. C. Gray (of Brook- 
lyn).** 

These writers have, with little or no qualification, accepted 
the Erb-Charcot views of tetanoid paraplegia. 

Two eminent physicians have, however, protested against 
these views as too exclusive, as tending to elevate the symptom- 
group to the rank of a well-defined disease. These are Profs. 
Westphalff andLeyden.^J Prof. Westphal relates in the Charite- 
Annalen an extremely interesting case of paraplegia with rigidity, 
a little diminution of sensibility and marked numbness in the 
lower extremities, without cystic or rectal paralysis. This 
patient had recovered almost perfectly at the date of writing the 
report (July, 1877). Assuming that the symptom-group in this 
case was similar to the spastic paralysis of Erb, Dr. Westphal 
proceeds to state his belief that paraplegia with rigidity may be 
produced by a variety of spinal lesions ; especially, in his ex- 
perience, by early and unrecognizable Pott's disease of the 
vertebra?. This last statement is in remarkable accord with the 
pathology of my own cases, three out of five having been of this 
nature. 

* 0. Berger. Die primare Sklerose der Seitenstrange des Ruckenmarks. 
Deutsche Zeitschrift fur praktische Medicin, 1876, Nos. 1G-19. 

Idem. Zur lehre von der pritnaren Lateralsklerose des Ruckenmarks. Deutsche 
Zeitschrift fur praktische Medicin, 1877, Nos. 3, 5, 6. 

f F. Richter. Zur Sklerose der Seitenstrange des Ruckenmarks. Deutsches 
Archivfur klinische Medicin, 1876, p. 865, Band xvii. 

X Seeligmiiller. Sklerose der Seitenstrange des Ruckenmarks bei verschiedener 
Kindern derselben Familie. Deutsche lied. Wochenschrift, 1876, Nos. 16, 17, 
Bandii., pp. 185-197. 

§ R. Schultz. Mehrere Falle von "Lateralsklerose." Archiv der Heilkunde, 

1877, xviii., p. 352. 

I M. Rosenthal. Traite clinique des maladies der systeme nerveux. Paris, 

1878, p. 406. 

1[ Von Stofella. Wiener lied. Wochenschrift, 1878, Band xxviii, pp. 565-594. 
London Medical Record, June 15th, 1878, p. 272. 

*•■ L. C. Gray. Spasmodic spinal paralysis. Proceedings of the Medical Society 
of the County of Kings, 1878, No. 29, p. 167. 

ff C. Westphal. Allmaliga enstandene Paraplegie mit Rigiditat. Charite-An- 
nalen, 1876, p. 372. Berlin, 1878. 

XX E - Leyden. Ueber spastische Spinallahnmng. Berliner Jclinische Wochen- 
schrift, 1878. Band xviii., pp. 706, 725. 
25 



386 PRESENT ASPECT OF TETANOID PARAPLEGIA. 

Prof. Leyden has very lately ably reviewed the subject in its 
various relations in a paper read to the Berlin Medico-Psycho- 
logical Society.* In this communication, while admitting that 
sclerosis of the lateral columns may be primary, and that this 
lesion will probably cause rigidity of the limbs below the lesion, 
he maintains his former position, to the effect that " spastic 
paralysis " often is the expression of a chronic dorsal myelitis. 
Experience since 1875 has convinced him that many spinal 
lesions may cause " spastic paralysis," as (1) traumatic myelitis, 

(2) compression of the spinal cord by Pott's disease or by tumors, 

(3) spontaneous chronic myelitis (disseminated sclerosis involv- 
ing the lateral columns), (4) spinal paralysis after acute disease, 
(5) syphilitic paralysis, and (6) spinal meningitis or peri-myelitis. 

Leyden proposes a clinical subdivision of spinal paralysis 
into two classes, supple or atonic paralysis, and tonic or spastic 
paralysis. 

The latter form (including the Erb-Charcot symptom-group) 
is explicable upon three hypotheses : (1) from increased excit- 
ability of motor nerves, (2) from increased excitability of the 
sensory roots of nerves, and (3) by partial or total interruption 
of the voluntary conduction from the brain to the periphery, 
with increased reflex power of the spinal gray substance. He 
lays the greatest stress upon the last-named explanation, which 
has a physiological basis in the experiments of Goltz (inhibit- 
ory action of the brain upon the spinal cord). I gave this ex- 
planation of the spasm in my cases in 1873. Another recent 
critic of the Erb-Charcot proposition, Dr. Eicklin f of Paris, has 
pointed out that a number of cases of so-called spastic paralysis, 
in the essays of Kichter, Berger, Schultz, and even Erb, might 
be looked upon as irregular cases of myelitis. He even objects 
to Stofella's case with autopsy, because of the absence of micro- 
scopic examination, and of any statement as to the condition of 
the upper spinal cord, mesocephale, and brain. Westphal and 
Leyden suggest that many of the cases of spastic paralysis now 
recorded are cases of localized (dorsal) myelitis, with secondary 
degeneration of the lateral columns below the lesion. It has 



* E. Leyden. Klinik der Ruckenmarkskrankheiten, Band ii., p. 445. Berlin, 
1875. 

\ Ricklin. De la paralysie spinale spasmodique ou tabes spasmodique. Gazette 
Medicate de Paris, 1878, pp. 321, 345, 369. 



PRESENT ASPECT OF TETANOID PARAPLEGIA. 387 

been impossible for me to read Berger's* and Seeligmuller's* con- 
tributions in the original, but with respect to Richter * I can say 
that his cases are much more like partial myelitis, or meningo- 
myelitis, than like spastic paralysis. Especially is this true of 
his case No. 4, which he reports as almost cured by electricity 
and hydrotherapy. Schultz * in his report, prepared under Erb's 
supervision, relates two cases (out of four) which are confessedly 
not typical. 

Nothnagel,f recognizing the general characters of a spastic 
case occuring under his observation (1876), relates it under the 
title of dorsal myelitis. 

A survey of the literature of tetanoid paraplegia would be in- 
complete without a consideration of a functional form of it, first 
described by Dr. L. A. Sayre, of New York, under the somewhat 
extraordinary name of spinal anaemia. His first paper was pub- 
lished in 1870,'J: and a second fuller exposition of his views was 
presented to the New York Society of Neurology and Electrology, 
March 1st, 1875, and printed in the Transactions of the American 
Medical Association for 1875. In these publications Dr. Sayre 
has described a form of spastic paralysis occurring in children, 
characterized by spasm of the adductor muscles of the legs, 
and of some muscles of the hands and arms, by paresis, and by 
a degree of inco-ordination. In many cases apparent idiocy was 
present, the clitoris or penis in these little sufferers was 
found red, irritable, and touching it produced local excite- 
ment and strong spasm in the limbs and body of the patients. 
Excision of the clitoris, circumcision, or simply tearing off and 
turning back an adherent prepuce, is reported to have wrought 
magical improvement in all, and a cure in most of the subjects. 

Dr. Sayre quotes (Transactions of American Medical Associa- 
tion, 1875) Dr. Barwell of London, in such a way as to lead one 
to suppose that the latter observer had met with cases of spastic 
paralysis dependent upon sexual irritation. A reference to Bar- 
well's l£cture§ will show that he described paresis and paralysis 

*L. c. 

f Nothnagel. Beobaehtungen liber Reflex-hemmung. ArcMv fur Psychiatrie 
und Nervenkrankheiten, Band vi., case ii., p. 336. 

\ L. A. Sayre. On reflex paralysis produced by phymosis and adherent prepuce. 
Transactions of American Medical Association, 1870. Vol. xxi., p. 205. 

Idem. Spinal anaemia with partial paralysis and want of co-ordination, from 
irritation of the genital organs. Transactions of American Medical Association, 
1875, Vol. xxvi.,p. 255. 

§ Barwell. Lectures on infantile paralysis. Lancet, 1872, Lecture iv., 1872, 
ii., p. 551. 



388 PRESENT ASPECT OF TETANOID PARAPLEGIA. 

in such cases, and not contracture, spasm or inco-ordination. 
Dr. Sabal, 6f Jacksonville, Florida, has met with cases like Dr. 
Sayre's, and has been successful in their treatment. 

While recording these statements as to the existence of a func- 
tional tetanoid paraplegia, it should not be forgotten that Dr. 
Eugene Dupuy,* now of San Francisco, has said, " Dr. Sayre has 
lately recorded some very interesting cases of contraction in 
young children which gave way entirely after the operation for 
phymosis. In some cases operated on by Dr. Sayre, the relief 
has not been of long duration, if I am to judge from what I have 
seen, as some of those young patients have been under my care 
since the operation performed by Dr. Sayre, and are as yet 
suffering as much as before from the same troubles." Even if 
we accept this statement of Dr. Dupuy, it seems probable that a 
functional spastic paralysis may exist. There is certainly 
nothing in physiology or in laws of morbid reflex actions to 
make such a condition impossible a priori. I have, however, 
never met with such a case either before or after an operation. 
As to Dr. Sayre's theory of spinal anaemia, it is hardly worthy of 
discussion, and I infer from the wording of his articles that he 
himself does not attach much importance to it. 

To conclude this clinical study of tetanoid paraplegia, I would 
briefly state my experience since writing my paper in 1873. 

In the first place, I believe the facts therein stated to have 
been well observed, though perhaps I may have overlooked 
paresis in some of my patients. In some of them, it is positively 
stated that while recumbent, their resistance strength at the 
knees was normal. Case III. was recognized as a case of amyo- 
trophic lateral sclerosis (Charcot) not long afterwards, and a 
complete post-mortem examination, which I have recently 
finished, has proved the correctness of this diagnosis. My 
explanation of the genesis of spasm is yet, I believe, tenable, and 
the chief error I am willing to admit is having too hastily drawn 
the conclusion that tumors compressing the cord were the ana- 
tomical cause of the symptoms. A more critical examination of 
Case IV. might have saved me from this error, as it was evidently 
a case of syphilitic myelitis in the dorsal region. 

'Second, I have met with several cases of dorsal myelitis (in 
accord with "Westphal, Nothnagel and Leyden), in which at a 

* Eugene Dupuy. Pathology and treatment of reflex motor symptoms, paraly- 
sis, contractions, etc. Journal of Nervous and Mental Disease, April, 1877, 
p. 232. 



PRESENT ASPECT OF TETANOID PARAPLEGIA. 389 

certain period well marked tetanoid paraplegia, or a spastic con- 
dition, set in. One of these was Case IV. of my essay. Another 
was a young man (treated in consultation with Dr. Charles 
McBurney in 1873-4), who recovered from a very severe attack 
of syphilitic paraplegia, and who for a long time suffered from 
stiffness and awkwardness of both lower extremities, with in- 
creased reflex. This mild tetanoid state gradually wore away, 
and the patient has now been for several years perfectly well. 
A third case was also one of severe syphilitic paraplegia, from 
dorsal myelitis, in which recovery progressed to a certain point, 
and remained stationary in spite of remedies ; the remaining 
symptoms being marked anaesthesia, paresis, great rigidity of 
the legs, especially when patient stood and tried to walk with 
crutches. Then the legs and feet were held tightly together in 
adduction, and only a violent effort enabled the patient to take a 
small step. Various forms of increased reflex were observed in 
this patient. A fourth case now under observation is that of a 
lady twenty-eight years of age, who in 1874, after confinement, 
had a severe complex illness in which myelitis played a part, 
and was paraplegic for several months. Since has had weak 
and numbish legs, with abnormal reflexes, especially of bladder 
and rectum. Her walk is done in small steps, the legs being 
very rigid ; no dragging of feet, no loss of equilibrium when 
standing with eyes closed ; legs strong enough when tested in 
bed ; knee and sole reflexes are very strong. 

Still another case is one of destructive central myelitis of the 
cervical enlargement, characterized by atrophic paralysis of the 
hands, forearms and one shoulder ; absolute anaesthesia up to the 
middle of the arms, partial anaesthesia of shoulders and parts of 
neck ; contraction of the left pupil, and tetanoid state up to the 
left lower extremity, without anaesthesia or atrophy. This 
tetanized leg is on the same side as the greatest atrophy and 
the contracted pupil. 

In the third place, I have seen several children with stiffened, 
contractured, adducted, and inco-ordinate limbs (upper and lower) 
co-existent with defective cerebral development. In other cases 
the legs alone were stiffened and adducted, and there were no 
symptoms in the upper extremities or head, and no sexual 
irritation. 

Dr. Erb* has recently described similar infantile cases, in 

* W. Erb. Ueber das A'orkommen der "' spastischen Spinallahmung " be?, kleinen 
Kindern. Memorabilien, 1877, 12 Heft. 



390 PRESENT ASPECT OF TETANOID PARAPLEGIA. 

which the legs alone were weak and tetanized, without alteration 
of sensibility. At the present time I have a fairly well-marked 
instance of the symptom-group in a child of six years attending 
at my clinic. 

From a careful consideration of the above data, I think that 
the only safe conclusions to be drawn now are : 

1. There is possibly a disease worthy of being called primary 
sclerosis of the lateral columns, and characterized by tetanoid 
paraplegia without anaesthesia, ataxia, atrophy, or affection of the 
bladder (Erb-Charcot view). 

2. There is very certainly a tetanoid paraplegia indirectly pro- 
duced by various lesions of the spinal cord, as pressure effects 
(Leyden and myself), syphilitic and non-syphilitic myelitis in the 
dorsal region (Leyden, "Westphal, Nothnagel and myself), amyo- 
atrophic lateral sclerosis (Charcot, Leyden and others), traumatic 
myelitis (Leyden), disseminated nodular sclerosis (Charcot — 
Case IV. of Betous' essay). Besides, the wonderful resemblance 
between the one-sided phenomena of late contracture in hemi- 
plegia of cerebral origin and tetanoid paraplegia must be borne 
in mind. 

3. It is probable that a functional tetanoid paraplegia exists 
in children, caused by genital or other peripheral irritation 
(Sayre).^ 

4. It is possible that tetanoid paraplegia cervicalis in young 
children may be due to defective cerebral development, and con- 
sequently agenesis of certain tracts in the cord. This is ren- 
dered probable by at least one case which has come under my 
observation, and by a consideration of the hemi-si3asm which 
follows grave cerebral lesions, and which we designate late con- 
tracture. 

If we now turn to pathological anatomy, we obtain instructive 
information. 

1. In the " true " spastic paralysis, Charcot and Erb claim 
that there is a primary sclerosis of the lateral columns of the 
cord. The opinion is based upon five autopsies : three by 
Turck,* one by Charcot, t and a more recent one by von Stofella 
of Vienna.* The claims of these autopsies to the rank of demon- 
strations is contested by several, especially by Ricklin.* The 
objections are that Turck's and Charcot's examinations were 
made in cases whose symptomatology was not well recorded, or 
* L. C. f L. C. Gaz. Hebd. 



PRESENT ASPECT OF TETANOID PARAPLEGIA. 391 

was that of another disease (hysterical contracture — Charcot). 
The last case, even though the autopsy was witnessed by Prof. 
Klob, is unsatisfactory, because (1) no microscopical examination 
was made ; (2) nothing is said of the state of the upper spinal 
cord, medulla, pons and brain, and (3) it is stated that the 
sclerosis (of the posterior part of the lateral columns) grew less 
and less in the cervical region. 

2. In the case which Charcot and Betous took for spastic 
paralysis, and which was found to have been disseminated 
sclerosis, numerous nodules were found in the lateral columns. 

3. In the late contracture of hemiplegia, which produces 
symptoms so much resembling tetanoid paraplegia, we now know 
beyond question that there is degeneration of the posterior 
part of the lateral column — the crossed pyramidal column of 
Flechsig. 

4. In the various diseases of the spinal cord which, in the 
experience of many observers besides myself, have been accom- 
panied or followed by a tetanoid state, we have good reason to 
believe that there was secondarv descending defeneration of 
the crossed pyramidal column. For example, in my case of 
cervical myelitis with stiff left leg, it can hardly be doubted that 
the left lateral column (crossed pyramidal column) has under- 
gone a degree of degeneration. 

From the above it appears almost certain that lesions of the 
crossed pyramidal columns have much to do with the develop- 
ment of tetanoid paraplegia, though we as yet lack a demonstra- 
tion of the existence of & primary sclerosis of these parts. 

A few months ago I should have been disposed to make the 
relation between sclerosis or degeneration of the lateral columns 
(crossed pyramidal column) and the tetanoid state of the limbs 
one of imperative causation, but since then, Dr. J. C. Shaw, of 
Brooklyn, has exhibited preparations of the spinal cord of a 
patient who had progressive muscular atrophy without a trace 
of stiffness of the limbs, and in the specimens there exists degen- 
eration of the ganglionic bodies of the anterior horns, and well- 
marked sclerosis of both crossed pyramidal columns. This 
sclerosis of the lateral columns was at least as well marked as 
in my own case of amyotrophic lateral sclerosis, in which the 
contracture was extreme. This rather puzzling case of Dr. 
Shaw's is published in the January number of Jewell's Journal of 
Nervous and Mental Disease, of this year. Quite a number of 



392 PRESENT ASPECT OF TETANOID PARAPLEGIA. 

cases of amyotrophic lateral sclerosis, in which sclerosis of the 
lateral columns was found without there having been any rigidity 
of the muscles, are on record. Chief among them are those by 
Dumenil, and by Barth. 

With the treatment and prognosis of tetanoid paraplegia, this 
review can have nothing to do. I would, however, remark that 
several cases have been cured, including one which was recently 
reported from Kussmaul's clinic at Strasburg, by Yelden. * 

The question of priority of description of the symptom-group 
tetanoid paraplegia, of first claiming that there is a paraplegi- 
form affection chiefly characterized by spasm, is one of minor 
importance, and I am quite ready to submit my claim in the 
language of Prof. Leyden,t " Wenigev bekannt ist, dass auch Seguin 
die spastiscJie Paralyse als erne besondere Form geschildert hat, unter 
dem etivas scliwerfalligen Namen der Tetanoid Pseudo-Paraplegia." 

-' Velden und Kussmaul. Fall von spastischen Spinalparalyse. Heilung. 
Berliner Minische Wochenschrt'ft, 1878. Band 15, p. 563. 
f L. C. Berlin. Klin. Woch., 1878, pp. 706, 725. 



THE USE OF THE ACTUAL CAUTEEY IN MEDICINE.* 

The question, " Where can an account of the actual cautery be 
found? " is so often asked me by students and practitioners, that 
I am led to believe that a brief statement of the mode of using 
this powerful agent in medicine, and an estimate of what it may 
reasonably be expected to accomplish, may prove interesting. 

First, as to the instruments and mode of application used in 
past times. A very incomplete study of the literature of the 
subject reveals the fact that cauterization was used by the oldest 
physicians, and that, with remarkable oscillations, it has dis- 
appeared and reappeared in medical and surgical practice in 
past centuries. 

About the end of the last century the celebrated French 
surgeon, Percy, made an elaborate report upon the subject of 
cauterization in general, in which he criticised the forms of 
cautery and their mode of application. His favorable report 
gave a great impetus to the use of this remedial agent. Surgeons 
have used it more than physicians, and the latter have continued 
to employ blisters, cupping, etc., for purposes of counter- 
irritation. 

Most various forms of cautery have been employed ; olivar, 
crescentic, linear, etc. 

Numerous materials have been employed to make the cautery ; 
iron, silver, gold, platinum, each metal being supposed to possess 
special advantages. The introduction of the platinum cautery 
is generally attributed to Dr. Brown-Sequard ; but I find that 
Hoppe, a German physician, proposed this apparatus in 1847. f 
However, it is to Brown-Sequard that we owe the demonstration 
that a platinum-tipped cautery is superior to the ordinary 
instrument, because it does not become oxidized and rough. 

Cautery irons made of steel, with variously shaped tips, are 
still generally employed by surgeons and by veterinarians, but 

* Reprinted from Archives of Medicine, April, 1879. 

f Hoppe. Das Feuer als Heilmittel, oder die Theorie des Brennens in Heil- 
kunde ; Bonn, 1847 ; cited in Diet, des Sciences Med., t. xiii., p. 408. 



394 USE OF THE ACTUAL CAUTERY. 

physicians, who see most of diseases of the nervous system, are 
unanimous in their approval of the platinum tip. 

The methods of using the cautery have been different at 
various times, and in the hands of various physicians and 
surgeons. The ancient method, which prevailed up to about 
1830, and is still in vogue, was to burn deeply ; to use force in 
applying the instrument, and to thus produce a slough which 
separated with suppuration. This severe application was made 
purposely, in accordance with the prevailing doctrines, which 
taught that suppuration was useful for the removal of disease. 
In late years deep cauterization has been used under the 
erroneous impression that a greater degree of irritation was 
thus produced. 

It is frequently stated, and I myself taught, that superficial 
cauterization, the method now chiefly employed in medicine, 
was introduced by Brown-Sequard. This is an error, since 
Jobert* (de Lamballe) as far back as 1838 described his 
" cauterisation transcurrente." Valleixf used superficial burning 
in the treatment of neuralgia about the same time and later ; 
and an elaborate essay upon the same mode of application (more 
especially for neuralgia) was published by Nota* in 1847, before 
Brown-Sequard had become engaged in the practice of the 
specialty in which he has since achieved such fame. 

Jobert, Valleix and Nota held that the cautery (made of steel 
and intensely heated) should be applied very lightly, in parallel 
strokes, over the nerves which were the seat of pain. They 
deprecated destroying the skin and causing supjouration. Their 
results in neuralgia were very remarkable. 

At the beginning of his practice, Brown-Sequard used the 
older severe application, and the moxa (treatment of Charles 
Sumner). Thus it appears that superficial cauterization as prac- 
ticed by Joberfc and Nota, had fallen into disuse prior to 1870. 

I come now to my own knowledge of the cautery and its appli- 
cation. When I had the privilege of studying with Brown- 
Sequard, in Paris, during the winter of 1869-70, he taught me 
the use of this counter-irritant. He was employing it daily in 
various diseases, organic and functional, of the nervous system, 
with apparently admirable results. His instrument consisted 

* Jobert. Etudes sur le systeme nerveux. Vol. ii., p. 648, Paris, 1838. 
f Valleix. Traite des Nevralgies, Paris, 1841. 
% Nota. Union Medicate, 1847. Tome i, p. 494. 



USE OF THE ACTUAL CAUTERY. 395 

of an olive-pointed steel cautery iron, about thirty centimetres 
long, the olive being about 15 mm. in diameter at the base, and 
carefully covered with platinum. He heated this instrument 
almost to a white heat in a grate fire, and applied it with ex- 
treme rapidity and wonderful lightness amd certainty of touch 
to the scalp, mastoid regions, back of neck, spine, track of various 
nerves, etc. He taught me that superficial counter-irritation 
was preferable for several reasons : 1, The greatest effect upon 
nerves was thus obtained, because the terminal filaments and 
terminal organs of sensory nerves are more sensitive than their 
trunks ; 2, Prolonged pain and suppuration were avoided ; 3, 
Patients were able to go about immediately after the operation. 
He also insisted upon the use of platinum-tipped cauteries 
because their surfaces did not oxidize and scale as did those of 
steel, and thereby a smoother and more superficial burn could 
be obtained. 

In 1870 Messrs. Tiemann of this city made for me, after my in- 
dications, platinum-tipped cauteries, similar to Brown-Sequard's, 
and I used them until 1876 with satisfaction. Since 1872-3 
they have been made by all instrument makers ; some olive- 
pointed, others button shaped, etc. Fig. 1 represents the olive- 
pointed platinum-tipped cautery. 



Fig. 1. — Platinum-tipped cautery of Brown-Sequard. 

The only serious drawback to the use of this form of cautery 
is the mode of heating. In order to obtain almost a white heat, 
a strong bright grate or range coal-fire is needed. In winter 
this can be had at all times in private houses and in our offices, 
but in summer the physician is obliged to have a fire made pur- 
posely, or to take his patient into the kitchen (as I have often 
done). Besides, grate fires are not to be had in hospital wards. 
Another disadvantage of this cautery is that through repeated 
heating the iron part of the instrument is gradually worn away, 
so that the platinum cap ultimately becomes quite loose. In 
other respects this instrument is excellent ; it is well balanced, 
and can, after some practice, be applied most lightly, so as to 
merely shrivel the cuticle ; it is sufficiently small to be carried 
anywhere with other instruments, or in a deep pocket. 

In 1876 a better instrument was introduced here by my friend, 



396 



USE OF THE ACTUAL CAUTERY. 



Dr. James J. Putnam, of Boston. This, the compound blow- 
pipe gas cautery, a modification of an English instrument, is 
represented in Fig. 2. 



CASWELL HAZARD SCO. 




Gas blowpipe cautery of Dr. Putnam. 



The instrument was exhibited before the American Neu- 
rological Association at its second annual meeting, June 7th, 
1876, and a description of it was published with the Proceed- 
ings of the Association, in July, 1876." I quote Dr. Putnam's 
concise description of the instrument : " It consists of a com- 
pound blowpipe with an appropriate handle, to the end of 
which a small platinum cup, fastened by three stout platinum 
wires to a brass collar, could be attached. A long and fine 
rubber tube ending in a brass tip for attachment to an ordinary 
fish-tail burner, carries the gas; a steady stream of air is 
pumped in by the aid of a rubber hand-ball and a receiver of 
very distensible rubber, in fact, an ordinary toy balloon covered 
by a good-sized bag of netted twine. 

" The advantages of the instrument over others, consist in its 
adaptability to almost any place where it is desirable to use the 
cautery, and the ease with which almost a white heat can be 
maintained for any length of time." 

I soon procured one of these instruments, -and used it with 
great satisfaction for nearly two years. For practitioners in 
cities and large towns it is very available, as it can be set going 
wherever illuminating gas can be procured. For physicians in 
small towns and in the country it is useless. 

Last year, however, a still more perfect and universally ap- 
plicable instrument was placed at our disposal. Paquelin's 
benzine cautery (Fig. 3), designed for surgical purposes, is 
admirably adapted to medical uses. It consists of a straight 

* The Journal of Nervous and Menial Disease, vol. iii., 1876, p. 434 



USE OF THE ACTUAL CAUTERY. 



397 



handle containing a blowpipe, and bearing a variety of platinum 
tips. Those for surgical purposes are pointed or flat in coarse 
imitation of knives. The tips suited for counter-irritation are 
the olive and the button. The olive or cone in my own instru- 
ment measures 22 mm. in length, and 12 mm. in diameter at 
its base. I had one side of it turned up so as to make the 
olive somewhat keel-shaped in one profile. 

The button-shaped tip is like a miniature cook's cap, 
measuring 13 mm. across the top, and 8 mm. in height. The 
upper rim of the cap projects nearly 2 mm., and with it I am 
enabled to make extremely narrow linear cauterizations. Each 
tip is fastened to a metallic collar which screws on the handle. 
Through the handle a stream of mingled air and benzine vapor 
is forced by means of a hand-bag and balloon. The balloon 




Fig. 3.— Paquelin's benzine platinum cautery. 



serves to make the current of air steady and continuous. From 
the balloon the air passes into a bottle containing benzine. The 
whole instrument is packed by Messrs. Tiemann in a small 
box. % 

The Paquelin cautery is managed as follows : After screwing 
on one of the tips, its platinum end is held in a flame — gas, 
candle, alcohol, or coal fire — until hot, and then air is pumped 
through the instrument. The mingled air and benzine ignite, and 
are projected as a flaming stream against the platinum tip ; and 
when this has become heated to a certain degree, a white heat 
is easily maintained after the removal of the instrument from 
the gas flame or fire. This increased combustion of benzine 
against heated platinum is very remarkable ; the process can 



398 USE OF THE ACTUAL CAUTERY. 

be kept up for a long time. It is important, I should add that 
the refined benzine sold in drug stores for cleansing clothing is 
too volatile to heat well ; the commonest benzine is the best. 
In the last few months I have employed this instrument 
altogether in my private practice, though still employing the 
Brown-Sequard cautery and Putnam's gas cautery in my clinic. 
It is at once evident that the Paquelin cautery is superior to 
all others in its being available anywhere, in town or country, 
providing the operator be supplied with benzine, and a flame or 
strong fire to start the combustion. Its cost is great, but 
probably before long a simple form of cautery, with one tip, 
may be supplied for less than twenty-five dollars. 

There is yet a fourth form of cauterizing instrument employed, 
viz., the galvano-cautery. I have not employed it, but recog- 
nize in it one advantage ; it is noiseless. The gas and benzine 
blowpipe cauteries make a hissing sound, which greatly alarms 
many patients. Obvious objections to the galvano-cautery are 
its cost, and the difficulty of carrying the whole apparatus to the 
homes of patients. 

In conclusion I would say that any of the above cauteries 
will suffice for medical purposes; they all satisfy the require- 
ments laid down by Brown-Sequard ; they are susceptible of 
being heated to a white heat, and being made of platinum, 
they remain smooth in spite of long usage. The choice of an 
instrument must be made chiefly upon the non-essential grounds 
of convenience and fancy. A glass rod heated in a spirit lamp 
has been proposed as a handy substitute for a cautery. It is a 
very inferior instrument, chiefly because it cannot be made very 
hot, because it bends and becomes unmanageable when hot, and 
because it cools very rapidly. 

I now pass to a brief statement of the methods of applications. 

Usually I follow the procedure called "cauterisation trans- 
currente " by Jobert and Nota, and adopted by Brown-Sequard, 
viz., I make very light parallel strokes with the cautery at white 
heat over the part chosen as the seat of counter-irritation. I 
aim to affect only the cuticle, and try to avoid subsequent sup- 
puration. From four to twelve strokes can be made in an in- 
credibly short space of time, and with very little suffering. The 
patient should be carefully placed with reference to the light 
and the comfort of the operator, and in many cases it is well to 
tell the patient to hold a handkerchief over his eyes. One 



USE OF THE ACTUAL CAUTERY. 399 

error to be avoided is striking hard at the beginning of the 
strokes, since that is certain to cause blistering and suppuration. 
Of course the best skill is baffled by sudden movements of the 
patient. The strokes should not cross one another, since at the 
point of crossing too much effect would be obtained. 

The only dressing required for a successful burning is a thin 
piece of old muslin or linen, which is to be pinned or sewed to 
the patient's underclothing. Burns behind the ear, or the 
upper cervical region, and on the face, require no cloth. In 
case of suppuration, simple cerate, carboiized cerate, or vaseline 
may be applied twice a day. 

It is often desirable to repeat the cauterization frequently. In 
spinal affections, for example, we may begin at the top, and by 
means of daily or tri-weekly applications, cauterize the entire 
spinal region systematically and repeatedly. 

With reference to the pain of the operation, patients differ 
greatly in their account of the sensations produced. The 
majority of my patients have considered the pain slight, and 
speak of its disappearance in twenty minutes or an hour. A few 
patients claim they suffer very much, and an equally small 
number declare that it is not at all painful, less painful 
than dry cupping. It seems quite clear to me that in most 
persons less pain is produced by the cautery than by a blister. 
Dr. Hammond recommends freezing the skin previous to apply- 
ing the cautery, but this seems to me highly unphysiological. 
I cannot here enter into a consideration of the modus agendi 
of counter-irritation, but can simply state that the modern 
doctrine of superficial counter-irritation involves irritating the 
terminal nervous twigs and organs, and obtaining distant reflex 
vascular and nervous effects. Xow, impairing or abolishing the 
irritability of the nerves of a region we are about to cauterize, 
seems hardly logical. It might be defensible for the older deep 
application, which was believed to relieve by the subsequent 
suppuration. I certainly advise cauterizing the active sensitive 
skin. 

The immediate result of the burning is a brownish welt with 
some roughness, due to shrivelled epidermis. Yery soon a zone 
of hyperemia appears around the streak, and lasts for a long 
time ; hours in some cases. When several parallel strokes 
have been made close together upon a part, an enormous cuta- 
neous hyper aamia results. This increased circulation is probably 



400 USE OF THE ACTUAL CAUTERY. 

a part of various vascular movements produced by the applica- 
tion, and necessary to its efficacy. Later results are a dry, brown 
scab, which falls off in a few days, leaving a red or reddish- 
brown scar, which disappears surely but slowly in almost every 
patient. 

The popular dread of the cautery is great, chiefly because of 
certain absurd accounts of the burning of patients which have 
appeared in the secular journals, and partly because the terms 
used — "burning," "cautery," — are alarming to all but most 
placid minds. Yet I do not think that it is right to cauterize 
patients by surprise, without a warning and explanation. I 
always tell my patients what I mean to do, how I mean to do it, 
and what the usual estimate of pain is. It is very seldom that 
I meet with a refusal to allow a first application, and after this 
trial no objections or complaints are heard as a rule. I have 
applied the various forms of cautery to persons of all ages from 
eleven to above sixty years, to both sexes, to persons of extremely 
nervous temperament, and in most various pathological con- 
ditions, and my experience has been so satisfactory that I now 
use the method more than ever, and consider it a more valuable 
mode of counter-irritation than any other. 

This account 01 the actual cautery has become so extended 
that I cannot do more than enumerate the diseases in which I 
have employed it, or known it to be employed with success. 
Superficial cauterization by the actual platinum cautery has 
been satisfactorily used in the following conditions : 

1. Neuralgias, acute and chronic, of the trigeminus, and of 
peripheral nerves. 

2. Spinal irritation, and the various cerebral paresthesia 
(pressure, numbness, etc.,) whose pathology is now obscure. 

3. Spinal congestion. 

4. Various forms of myelitis, acute and sub-acute. 

5. Epilepsy (not by myself). 

6. Intercostal pain. 

7. Lumbago, acute and chronic. 

8. Articular inflammation. (White swelling of knee by Dr. 
McBride ; traumatic arthritis of wrist, by myself.) 

9. Peri-arthritis (chronic rheumatism?), especially of the 
shoulder. 

In general terms the cautery is a potent and harmless substi- 



PEDAL NEURALGIA CURED BY ACTUAL CAUTERY. 401 

fate for blisters and pustulating ointments, in the various 
affections where counter-irritation is called for. 

I trust that I will not be misunderstood as holding the actual 
cautery to be a panacea, and as urging its indiscriminate use. 
It is a remedy which, like all others, is to be employed only when 
indicated. The promiscuous burning of patients who present 
themselves with obscure nervous symptoms, or who are hypo- 
chondriacal, I unhesitatingly condemn. 



TRAUMATIC PEDAL XEUEALGIA OF OXE YEAR'S 
STAXDIXG RAPIDLY CURED BY THE ACTUAL 
PLATIXUM CAUTERY.* 

Dr. K g, aged 50, seen December 25, 1877. Is a man of 

good constitution ; never subject to neuralgia. A little over two 
years ago one wheel of his wagon passed over the end of his right 
great toe, producing a moderate bruise but no fracture, luxation, 
or cut. In a few days he was perfectly well. In the last twelve 
months has suffered from gradually increasing pain in the toe 
which was injured, and along the inner side of the sole of the 
foot as far back as the ankle. The pain is burning, pressing, 
aching, not lancinating. It is worse in the daytime, and is 
aggravated by using the foot. No numbness or anaesthesia has 
been observed, but, on the contrary, there has been great hyper- 
algesia of the affected region, with some tumefaction and great 
hyperemia. Xo pain above ankle ; but patient has " fancied " 
that he had slight " sympathetic " pains in the left great toe and 
in the pulp of the right thumb, when the pedal neuralgia was 
greatest. Xo head symptoms ; no signs of paraplegia ; bladder 
normal. Xo gout. Has been confined to the house for four and 
a half months. 

Examination. — Right great toe and inner half of foot tumefied 
and red ; the veins are large and there is much capillary stasis. 
Xo nodosities or other lesion exist about the affected toe. Xo 
true neuralgic tender point can be discovered, but some time be- 
fore Dr. K. discovered one beneath the internal malleolus, near 
the sole. The whole right toe is very tender, and the chief pain 
is experienced along the internal aspect of the toe to its point. 

* From Archives of Medicine, June, 1879, toI. i. 
26 



402 PEDAL NEURALGIA CURED BY ACTUAL CAUTERY. 

The left great toe is rather reddish but not tender. When 
patient stands the passive congestion becomes enormous, and 
extends almost up to the groin. Repeated measurements by Dr. 
K. and myself show that the right foot (back of toes) is .5° C. 
hotter than the same part of the left. 

The doctor bears the facial expression, and has all the attitudes 
of one who has suffered greatly from neuralgia. He has tried 
nearly all remedies and applications without relief. 

Diagnosis. — Traumatic neuritis of branches (and trunk?) of 
the internal plantar nerve. 

I employed the actual platinum cautery applied over the pos- 
terior tibial nerve behind the malleolus, and on the seat of pain ; 
no medicine was given. The first application gave relief ; after 
the third burning Dr. K. was able to walk, and after the sixth 
the neuralgia disappeared ; these cauterizations were made at 
intervals of two days. The great hyperemia of the lower ex- 
tremity continued. Dr. K. resumed his practice. 

Early in May, 1878, a slight relapse occurred, which was com- 
pletely cured by two or three applications. Since that time there 
has been no return of neuralgia, though the toes are the seat of 
slight semi-painful or cramp-like sensations. The hyperemia 
had almost disappeared by autumn. In the past year the patient 
has not lost one day from neuralgia. 



CASE OF DESQUAMATION OF THE KIDNEYS DUR- 
ING THE ADMINISTRATION OF MEECUEY AND 
IODIDE OF POTASSIUM.* 

A youth of 19 was under my care during the last half year for 
symptoms of cerebellar tumor, viz., epileptiform attacks, occipi- 
tal headache, partial opisthotonus, moderate neuro-retinitis, 
partial right hemiplegia, ending in death. The urine was ex- 
amined in the autumn and found normal. In December, 1878, 
the occipital pain and spasm became very severe, partial right 
hemiplegia showed itself, and the patient was given the red 
iodide of mercury, .01 gram, and iodide of potassium, 2 grams, 
four times a day ; blisters were applied behind the ears. Im- 
provement showed itself early in February, and about that time 
the urine was examined because of its great quantity. What 
was my surprise at finding in it an enormous number of hyaline 
and epithelial casts. There was no albumen, and the patient 
had no other symptom of renal disease. From February 13th 
to March 7th, numerous examinations were made, with the fol- 
lowing results : urine of good color, specific gravity varying 
from 1,018 to 1,020, absolutely free from albumen, depositing 
innumerable casts of all sizes, hyaline and epithelial. In some 
instances eight or ten casts were counted in a field. Prof. A. L. 
Loomis examined two slides containing these casts. At Dr. 
Loomis' suggestion the medicines were stopped February 17th. 
Until February 24th, casts were still detected in diminishing 
number, hyaline casts being the last observed. The iodine 
reaction also persisted for at least a week after the stoppage of 
the iodide. On March 7th, it is noted that no casts are to be 
found, and this negative result was obtained on several other 
days. 

About March 24th, after a remarkable remission of two weeks 
(walking about the house), the epileptiform attacks, opisthotonus, 
and severe occipital pain recurred, and the mixed treatment was 
once more begun. The amount of mercury and iodide of potas- 
sium given in this relapse was about the same as before (.01 
* From Archives of Medicine, June, 1879. 



404 THE URINE DURING MIXED TREATMENT. 

gram and 2 grams four times a day), with extra doses of iodide 
alone afterward. On some days the patient took nearly 15 
grams. On April 9th, the urine had a specific gravity of 1,018, 
contained 1 per cent, albumen, and an immense number of 
hyaline and epithelial casts ; also free renal epithelium. As 
before there were no symptoms of renal disease. Several other 
examinations were made previous to death on April 18th, with 
the same result as regards casts. The last two days were char- 
acterized by a steadily rising temperature up to 41.26° C. 

The symptoms in life, and the mode of death, indicated organic 
cerebral disease, whether a chronic basal meningitis or a cere- 
bellar tumor we were unable to decide, as a post-mortem exam- 
ination was refused. 

The most interesting point in the case was the occurrence of 
severe renal desquamation on two occasions, apparently caused 
by iodide of potassium, or by it and mercury combined. That a 
few hyaline casts may appear in the urine of patients taking 
iodide is generally known, but the. shedding of enormous quan- 
tities of epithelium was startling. It should be remembered 
that the first desquamation ceased about one week after the 
iodide was stopped, and that the iodine color and the casts dis- 
appeared about the same time. 

My friend Dr. F. P. Kinnicutt communicates another case 
which occurred in his practice. I quote the doctor's notes : 
" The patient was taking .003 gram of biniodide of mercury and 
.75 gram of iodide of potassium three times a day for secondary 
syphilis. On March 23, 1877, he contracted an urethritis. 
Examination of the urine showed numerous leucocytes and 
hyaline casts. The latter were of varying size, but all of similar 
character. There was a mere trace of albumen, easily accounted 
for by the number of pus corpuscles. With the complete cessa- 
tion of the urethritis (in three weeks), the trace of albumen 
disappeared, not to return. Hyaline casts, however, continued 
to be found in great numbers. On May 20th, the casts were 
still present in the same numbers. The iodide of potassium was 
discontinued, but the mercury was not omitted. "Within a week 
after the discontinuance of the iodide, the casts were fewer in 
number, and early in July had notably diminished. Patient 
went into the country at this date ; on his return in November a 
careful examination of the urine failed to show a single cast. 
[Mr. B. had been under my observation previous to his having 



FOLIE 1 DEUX. 405 

contracted specific disease ; his urine had been examined and 
found healthy. During the period that casts were found the 
patient's general condition was excellent in all respects. The 
urine has been examined from time to time up to this time, and 
at no time have any casts been found. The iodide of potassium 
was never resumed.]" 

It would seem from these two cases (to which I might add a 
third now under observation), that iodide of potassium may give 
rise to the formation of hyaline and epithelial casts, without 
albuminuria or rational symptoms of Bright's disease. 



"FOLIE A DEUX." 

AN INSTANCE OF APPAKENT CONTAGION OF INSANITY (MELANCHOLIA). * 

K. L., aged 28, a single woman, seen in consultation with Dr. 
A. Jacobi, May 19th, 187- There is a complex history of nervous- 
ness, hypochondriasis, and approach to hysteria in the last two 
years. Lately well-marked hypochondriacal melancholia, with 
constant talk of disease of the brain, extraordinary symptoms, 
etc. Patient has the facies and manner of a hypochondriac. 
Inquiry has revealed the important fact that for some time 
patient has practiced self-abuse, and has endured great self- 
reproach in consequence. Seen again on June 3d. Is in full 
acute melancholia, refusing food, attempting suicide, not sleep- 
ing, growing weaker. Sent to asylum. 

P. L., a sister of the preceding patient, aged 25 years ; was 
seen on June 12th. During the illness of K. L. she had become 
nervous and depressed, and was removed from home to some 
friends. But she there grew worse, and at the time of K.'s 
commitment (June 3d) she was decidedly melancholic ; reproach- 
ing herself for having caused her sister's ruin, declaring that 
she was not fit to live, etc. It appears that these two young 
women had slept and masturbated together. When seen June 
12th, fully developed acute melancholia is observed ; is worse 
than her sister. Sent to the asylum. 

The mother of the patients had once been insane. 

It is interesting to add that both these patients recovered 
within eight months, and are now well. 

* From Archives of Medicine, June, 1879. Vol. i. 



i06 FOLIE A DEUX. 

These two cases well illustrate the aetiology oifolie a deux, or 
contagious insanity, as explained recently by Falret and Lasegue 
in an inrportant memoir."" It is not the exhibition of the 
insanity of the first party which causes the insanity of the 
second party ; in other words there is not a true contagion. 
Both parties must be predisposed to alienation, must live in the 
same moral atmosphere, be exposed to the same exciting causes, 
and experience similar or corresponding emotions and con- 
ceptions. 

These conditions of apparent contagion, or nearly simultaneous 
development, were found in all of Lasegue's and Falret's cases, 
and they are well exemplified in ours. Both the patients were 
children of an insane parent, both had enjoyed certain emotions 
and committed physical excesses together, both felt acute 
remorse for the vicious indulgence, and the second suffered in 
addition moral torture from the notion that she was responsible 
for her sister's illness. 

35 La folie a deux, ou folie communiquee. Annates 3Iedico-Psychologiques, 
Nov., 1377. p. 321, 



CASE OF HEMIPLEGIA WITH FIRST SYMPTOMS IN 
THE FOOT, AND A LIMITED CORTICAL LESION * 

I venture to acid this imperfect case to the admirable one 
reported by my friend Dr. Miles, because, with certain allowances, 
it may serve in the discussion about the effects of cortical 
lesions. 

In November, 1878, I saw, in consultation with Dr. Granniss, 
of Saybrook, Ci, a gentleman aged 54 years, who was hemiplegic 
on the left side and almost unconscious. The following account 
of his illness was furnished : 

In December, 1877, after having enjoyed good health, he awoke 
one night with clonic convulsions of the left toes, foot and leg 
only. There was no impairment of consciousness, no spasm in 
any other part. He watched the spasm some time, and made 
comments on it. Since, there has gradually developed a left- 
sided hemiplegia. For months only the foot and leg were 
paretic ; in the last few weeks the left arm has become weak, 
and now the left cheek is paretic, though the relatives have not 
noticed it. In January, 1878, vision became impaired, but an 
examination by Dr. Noyes revealed no cause. In the last few 
weeks patient has seen double at times, and sight has gradually 
failed. Severe headache has existed from the first ; frontal, 
bilateral pain, most marked on the right side. This pain has 
been worst about daylight. In the past month pain decidedly 
nocturnal. On a number of occasions "lost himself" while out 
of doors, not remembering where he had been (petit-mal ?). 
A business associate thinks that patient has committed errors in 
judgment. No extravagance in design or in deed. Lately has 
become stupid and semi-comatose. 

Since January, 1878, a tumor-like swelling has appeared over 
the right parietal region. No albuminuria, but has had several 
attacks of gout. After severe cross-examination, patient admits 
having had a chancre, fifteeen years ago, treated with mercury ; 
denies secondary and tertiary symptoms. 

* From Archives of Medicine, Aug., 1879. 



408 



CORTICAL LESION: FIRST SYMPTOMS IN FOOT. 



Examination showed a typical left hemiplegia, face and limbs. 
No diplopia, pupils small and equal ; after atropia there is found 
a well-marked double neuro-retinitis. Sensibility preserved on 
the paralyzed side. Articulation indistinct ; no aphasia. Stupor 
is peculiar, like that of drunken sleep. ♦ Patient can be roused 
by loud talking and shaking, and then answers correctly (showing 
fair memory) and clearly. The swelling upon the head, raised 
perhaps half an inch, is just above the right parietal eminence, 
extending inward to the median line, and forward almost to the 
vertical line from the meatus auditorius to the bregma. This 
tumor overlies Ferrier's centres for the legs. 

Diagnosis. — External and internal nodes involving dura mater 
and the subjacent gyri of the right hemisphere. 




A few days later the patient died comatose, and after much 
trouble Dr. Granniss secured a partial autopsy. He was not 
allowed to raise the brain from the skull or to incise it. He 
simply removed the calvarium and noted the lesions at the 
vertex. He found that there was an internal as well as an 
external osteitis, forming quite a tumor, which had, after adhering 
to the dura, exerted great pressure upon the subjacent convolu- 
tions. Dr. Granniss marked the location of the cortical lesion 
upon an Ecker's diagram, and the annexed wood-cut is a copy 
of his sketch. 

It is of course very much to be regretted that a thorough 
examination of the brain was not permitted, but in view of 
numerous recent cases, it is impossible not to admit a causal 
relation between the lesion causing pressure upon the inner end 
of the right ascending frontal and parietal convolutions and the 
symptoms in the left foot and leg — spasm and paralysis. 



CASE OF SLOW PULSE AND EPILEPTIFOBM CON- 
VULSIONS.* 

H. G., aged 43 years, seen in consultation with Drs. Wm. Detmold and S. 
S. Jones in September, 1875. Present illness dates back more than one year. 
In former life, in adult age had frequent attacks of ' ' glimmering before the 
eyes," lasting from a few minutes to half an hour, and invariably followed by 
headache, lasting nearly all day. Never observed absolute blindness in these 
attacks. These seizures have become fewer in the last few years ; none in 
eight months. In the spring of 1874, patient consulted Dr. Detmold on 
account of a number of severe epileptiform attacks, without biting of tongue 
and subsequent drowsiness. It was then for the first time observed that the 
patient's pulse was very slow, from 24 to 28 beats per minute. Under tonics 
the pulse-rate increased slightly. 

The patient describes some of his attacks as consisting chiefly in a want of 
breath, and severe constriction about the chest ; no actual pain, and no symp- 
tom of angina pectoris. In some attacks he is a little dizzy, and even loses 
consciousness for a moment. These seizures have been very frequent, day 
and night. Even in the worst attacks the patient has never injured himself. 
Dr. Jones saw him in one epileptiform seizure ; he then seemed like a man 
struggling against asphyxia, had clonic spasms, and a bluish face ; the pupils 
were not examined ; consciousness was not perfectly lost. 

Examination. — Patient is a medium-sized, spare and pale-faced man. He 
sits naturally, and walks slowly but well around the room. Features anxious 
and drawn, suggestive of hypochondriasis, no headache. Nothing abnormal 
about the head. Some ten days ago Prof. J. H. Knapp examined the eyes 
with the ophthalmoscope aud found them normal. No paresis, numbness 
anaesthesia, etc., in the limbs. The pulse beats 26 and 27 per minute in two 
counts (not successive) ; the artery seems tense, and by the finger one would 
describe the pulse as pulsus tardus et durus, no enlargement of veins, or evi- 
dence of embarrassment in the capillary circulation. The heart's impulse is 
very faintly perceptible to the finger in the fifth intercostal space within the 
nipple line ; the dullness area is not increased. The cardiac sound ^are almost 
normal ; the impulse movement (systole) is apparently a rolling one, with a 
slight, inconstant systolic murmur, best heard over the cartilage of the fifth 
rib between the outer edge of the sternum and the nipple. It is probably an 
unusual contact sound of heart against the parietes. At the apex of the right 
lung there are slight dullness, increased vocal resonance, and prolonged expi- 
ration. Much nervousness (even to crying) has been observed, and patient 
has been disposed to magnify all his symptoms. Urine normal ; no sign of 
tumor in cervical region near the vagi. 

* From Archives of Medicine, Aug., 1879. 



410 SLOW PULSE AND EPILEPTIFORM CONVULSIONS. 

The pulse-tracings appended were taken with Marey's sphyg- 
mograph. Fig. 1 was made under a low degree of pressure and 




Fig. 1. 



perhaps gives the better picture of the pulse, with its high ten- 
sion, and attempt at an extra beat in one place. Fig. 2, made 
under high pressure, shows a less normal dicrotism, and an 
imperfect ending of the systolic impulse ; tension less. Both 
tracings indicate a want of perfect regularity in time and form 
in the various beats. * 




Fir. 2. 

Kemarks. — This case is remarkable, but not unique. Many 
cases are on record in which the pulse-beats ranged from 16 to 
32 per minute. My friend, Prof. Cornil, of Paris, has placed on 
record t an instance of 14 beats ; Landois, % one °f 10 beats. In 
several of these cases (Bradbury, § C. H. Jones II) "syncopal 
convulsions " and " epileptoid attacks " occurred. 

The explanation of epileptoid attacks in cases of slow pulse 
does not appear difficult. The brain, and especially the basal 
masses, are rendered anaemic for too long a time. In other words, 
a degree^of asphyxia (want of oxygen or excess of carbonic acid) 

* The lower diastolic part of the first beat in Fig. 1 is imperfect, because the 
lever descended too low and ran along the paper-holder for a moment. 

f V. Cornil, Comptes-Rendus de la Societe de Biologie, 1875. T. 2, 6 me series, 
p. 248. 

\ Landois, Die Lehre von Arterienpuls, 1872, p. 228. 

§ Bradbury, Case of infrequent pulse and syncopal convulsions ; death, autopsy. 
Lancet, i., 1877, p. 493. 

I C. Handfield Jones, Lecture on slow pulse and epileptoid attacks. Lancet, 
1876, vol. ii., p. 919. 



SLOW PULSE AND EPILEPTIFOBM CONVULSIONS. 411 

is produced in these parts, and a discharge of nerve force takes 
place. The human being is thus placed in a condition resem- 
bling that of the animals whose subclavian and vertebral arteries 
were tied by Astley Cooper, Kussmal and Tenner. These ob- 
servers first demonstrated by such experiments that anaemia of 
the basal parts of the encephalon will give rise to epileptoid 
attacks. 

It is singular that in H. G. we did not observe the Cheyne- 
Stokes' respiration rhythm, which is believed by many to be 
due to temporary asphyxia of the medulla oblongata. 

"We might add another case of slow pulse to this contribution, 
but, unfortunately, the notes and tracings have been mislaid. 
However, I can distinctly recollect that the patient, a male, 
about thirty-five years of age, was apparently not disabled by 
the slow action of his heart, though he had been somewhat weak 
for months prior to being seen. The pulse beat about 32 per 
minute, but the patient stated that it had been slower. No car- 
diac disease existed in this case, and no epileptiform attacks 
ever occurred. 

In such cases it is a matter of surprise how the system at 
large can become accustomed to such a slow pumping of the 
blood. In both patients the principal organs, except the basal 
region of the brain in the first case, were normal ; the lungs, 
liver, kidneys and various glands acting as well as if they received 
fresh oxygenated blood sixty or seventy times per minute. 
Calorification and the peripheral circulation were normal. In 
such cases we see a wonderful example of the self-regulating 
and accommodating qualities of a complex organism. 

The causes of slow pulse are various. Some few individuals 
have a normal slow rate — down to fifty or forty beats. Again in 
some case of ursemic poisoning a very slow pulse may appear. 
Third, pressure upon the brain (clots, tumors, clejjressed bone) 
often reduce the pulse rate and raise the tension. But none of 
these pathological conditions can, so far as we know, bring the 
pulse down to the extreme figures referred to, viz., ten, fourteen, 
twenty-one, twenty-six, twenty-eight, or thirty per minute. Per- 
haps the best physiological explanation of very slow pulse is by 
irritation of the vagi in the neck, or more probably near their 
origin. In our two cases none of the above-mentioned condi- 
tions could be demonstrated. 



A CONTRIBUTION TO THE PATHOLOGY OF ACUTE 
CENTRAL MYELITIS.* 

The case had a history briefly as follows : A male patient, set. 
33, unmarried, originally of good constitution, infected with 
syphilis, not conscious of straining his back or of catching cold, 
at 430 p.m., Oct. 8th was taken with pain in the lumbar region, 
located over the kidneys. Soon after he made ineffectual efforts 
to micturate ; at 9.30 p.m. he made ineffectual efforts to empty his 
bladder, and was not able to sleep; at 11.30 p.m. he had great 
desire to micturate, and when he arose from his bed found that 
he was unable to stand. There was tingling in his toes and 
feet, and marked anaesthesia. The sensation at the knees was 
apparently perfect. He was restless, and his anxiety was great 
during the after part of the night. Pulse, 120 ; temperature, 
378° C. 

Oct. 9th, 3 p.m. Anaesthesia had extended upward to the level 
of the umbilicus ; paralysis complete below. Catheter was 
used, an enema of soap and water was retained. At 8 p.m. he 
suffered from much pain in the sides of abdomen, lower part of 
thorax, and epigastrium. No symptoms referable to the hands 
or arms. Lower extremities absolutely paralyzed and anaes- 
thetic. Spine only slightly tender in its medio-dorsal region ; 
extremely restless ; no dyspnoea. 

Diagnosis. — Acute myelitis with softening, involving the entire 
thickness of the cord at a point in the lower dorsal region. 
The attack bore all the clinical characters of an acute inflam- 
mation from exposure to cold. He then suffered from a dis- 
tressing sense of constriction about the body. On the fifth day 
of his sickness a strong faradic current was applied* one pole 
high in the rectum and the other over the abdomen, and an 
evacuation of the bowels obtained. In the third week there was 
notable atrophy of the muscles ; and the level of the anaesthesia 
was at the ensiform cartilage. There was fever throughout the 

* By Dr. E. C. Segnin in collaboration with Dr. E. K. Henschel. Reprinted 
from the N. Y. Medical Record, Nov. 29, 1879. 



PARAPLEGIA IN SYPHILITIC SUBJECTS. 413 

course of the disease, and the patient lived two months after 
the first development of symptoms. 

A remarkable fact, relating to temperature, was that the tem- 
perature of the toes was higher than that of the body for the 
first few days. 

Autopsy less than twenty-four hours after death : Enormous 
bed-sores over the sacral region. The spinal cord measured 
32.5 cm., from the point of section, in the lower cervical 
region, to the filum terminate. The lower dorsal region was the 
seat of marked swelling and evident softening. The cord was 
carefully hardened, first in absolute alcohol, and then in bichro- 
mate of potassa ; and, when examined microscopically, pre- 
sented the following lesions : Descending degeneration of the 
postero-lateral columns ; ascending degeneration ; nearly com- 
plete destruction of the anatomical elements at the seat of the 
greatest softening. Several ganglion-cells contained vacuoles ; 
vacuoles and contents apparently quite unaffected by reagents. 
The coats of the blood-vessels were thickened. There were 
granular bodies — whether they were the granulation corpuscles 
or not, was undecided. Neuroglia thickened. Acute central 
softening. 



PARAPLEGIA IN SYPHILITIC SUBJECTS.* 

I avoid the common term " syphilitic paraplegia," for several 
reasons : 

1. It is not very scientific, because the present tendency is 
toward an anatomical classification. 

2. The relation between syphilis and existing paraplegia in a 
given patient is often a matter of great uncertainty. 

3. Paraplegia, which improves under the use of mercury and 
iodide of potassium, is believed by many to be syphilitic, 
whether the patient admits or denies syphilis. 

4. There are no definite symptom groups, which inform us 
that syphilis has attacked the spinal apparatus. 

In the histories of four cases related the following were some 
of the interesting features which they presented : All four 

* Read at. meeting of N. Y. Neurological Society, March 3, 1879. Reprinted 
from the N. Y. Medical Record, April 5, 1879. 



414 PARAPLEGIA W SYPHILITIC SUBJECTS. 

described chancres, and had secondary symptoms. The time 
which elapsed before the paraplegia began was variable, as fol- 
lows : In one case twenty-six months ; in one six months ; in one, 
ten months ; and in one, seven years elapsed after the develop- 
ment of the initial lesion before paralysis manifested itself. 
"With one exception the development of the paraplegia was rapid. 
There was paralysis of the bladder in all four cases, thus indi- 
cating lesion in the dorsal region of the cord. The attacks were 
all severe. Complete cure was obtained in only one case. There 
was a remarkable amelioration of symptoms in all the other 
cases. 

Two cases were then reported which illustrated mistakes in 
diagnosis. In one case there was the exceptional symptom, 
namely, marked staggering when the eyes are closed, yet no anaes- 
thesia of the soles of the feet. 

I think tliat at the present time we are not able to make a 
positive diagnosis of paraplegia dependent upon syphilis. Para- 
plegia of syphilitic origin is usually atypical. It was far from 
proven that no diseases were cured by mercury and iodide of 
potassium, except syphilitic affections. 

The treatment of paraplegia occurring in syphilitic subjects 
should be energetic, and should be carried on by the simultane- 
ous use of mercury and iodide of potassium. The iodide of 
potassium should be used after the American method — fear- 
lessly ; and even as much as 32 grams can be administered 
daily. Tonics were frequently required, and the best was cod- 
liver oil. It was important to keep the bladder empty so as 
to prevent or reduce cystitis, and to prevent bed-sores. In con- 
clusion, I would call the attention of the society to the following 
points : 

1. The question of diagnosis ; was it possible ? 2. The manner 
of giving mercury and iodide of potassium in this affection. 
3. The value of the therapeutical argument in diagnosis, post hoc; 
and 4 The prognosis in paraplegia occurring in syphilitic sub- 
jects. 



A CASE OF MOVABLE KIDNEYS; EEMAEKABLE 
VOLUNTARY CONTBOL OVER THESE ORGANS * 

Mes. V., an American, aged about 31 years, consulted me on 
October 7, 1879, for " Nervousness " which had lasted eight or 
ten years. On examination I found she was hysterical, debili- 
tated, dyspeptic, and that her uterus was moderately anteflexed 
and anteverted. Her last child was born four years ago. In 
the succeeding year, three years ago, she suffered for a whole 
winter from repeated attacks of severe hepatic colic, vomiting 
and subsequent jaundice ; a few gall stones were seen in the 
faeces. 

In the course of her detailed story, Mrs. V. mentioned that 
some time after these attacks of colic she had noticed " lumps " 
in her abdomen, and that they have been present ever since, 
making their appearance and moving about under her control. 
One physician had told her these lumps were " muscle," another 
that it was " the liver." They had never caused her any pain. 

Examination of the abdomen in the recumbent posture showed 
a slim-built body, but little covered with fat ; simple palpation 
showed nothing abnormal, deep pressure in the left side of the 
abdomen just below the ribs, revealed an obscure sensation of a 
rounded solid body. The patient now brought down her kidneys. 
By a powerful expiratory effort, drawing the lower ribs down- 
ward and inward, thus compressing the upper part of the 
abdominal contents, the organs made their appearance under the 
hand, and could be felt and grasped, they were globular, firm, not 
tender. The left kidney presented at a point distant 7 cm. from 
the median line, and about on a level with the umbilicus, or 
half way between the lower border of the ribs and the crest of 
the ilium. The right kidney escaped from under the lower 
border of the liver, and presented at a distance of 9 cm. from 
the median line ; not descending much below the edge of the 
liver. Upon the cessation of the expiratory effort the organs 
disappeared from these locations. The left kidney is much more 
movable than the right. 

* From the Archives of Medicine, December 1, 1879. 



416 CEREBRAL HEMORRHAGIC PACHYMENINGITIS. 

The other organs of the abdomen seem quite normal in size 
and position. The urinary secretion has always been free — too 
free often. 

The interesting points in the case are : 

1. The occurrence of double dislocation of the kidneys. 

2. The ability of the patient to make the loosened organs 
descend and present under the anterior abdominal walls. 

3. The probable aetiology, through the strong muscular efforts 
attendant upon hepatic colic. 

I may add that statements relative to the uterine and renal 
displacements were corroborated by my friend Dr. Paul F. 
Munde. 



CASE OF CEEEBEAL HEMOEEHAGIC PACHY- 
MENINGITIS.* 

Mr. X — , set. 68, a merchant, seen on September 19, 1879, with 
Drs. Abbe and Herrick. The patient's general health had been 
excellent for years. In July of this year he had what was 
called a partial sun-stroke. About the last week of August 
returned from a trip to Colorado, looking badly. 

A few days after return, a " neuralgic " headache set in on 
the right side, and has continued, with intervals of from two to 
five days, until now. Within ten days from the beginning of 
this headache a most remarkable failure of muscular strength, 
not of paralytic form, manifested itself. Pain has been very 
severe, and more generalized (less neuralgic) in the last three 
or four days ; severe at night. Since the 17th (two days ago) 
great restlessness, physical and mental apathy and failing 
strength have been observed. No aphasia symptoms. A more 
important symptom has also appeared, viz. : a slight stiffness, 
with occasional clonic spasm of the right arm and hand. The 
right cheek has been thought flabby. 

Mr. X. has been indisposed to use the right arm and leg, and 
has preferred to lie in bed. The pulse, in the last two days, has 
risen to between 70 and 80, after having been slower. The 
axillary temperature has risen to 37.4° C. Memory unimpaired ; 
no albuminuria. Pain in head now diffused and frontal. 
* Reprinted from the N. Y. Medical Record, Jan. 24, 1880i 



CEREBRAL HEMORRHAGIC PACHYMENINGITIS. 417 

Examination. — Patient lying on his back, with his right fore- 
arm and hand in the semiflexed and adducted position charac- 
teristic of contracture. Intelligence preserved ; answers are 
slow, but correct, yet patient is indifferent and dull. Pupils 
normal ; right orbicularis palpebrarum is the seat of constant 
clonic spasms, which extend to frontalis and other facial muscles. 
No twitching of right hand during the visit. Moves all limbs 
voluntarily, but extension of right arm and hand is incomplete, 
and there is marked rigidity (to passive motion) at elbow and 
in fingers. Mouth is drawn a little to the right (spasm) ; tongue 
is projected straight ; articulation good ; uses words correctly. 
No cardiac murmur, second sound hard, arteries tense ; no red- 
ness on nates. In last two days involuntary, and, to a certain 
extent, unconscious micturition ; patient is now wet without 
knowing it. No retention. Was always right-handed. 

The symptom diagnosis was partial right hemiplegia, and it 
seemed to me that the most likely anatomical cause of such a 
peculiar paresis with hemispasm (face) was gradual interference 
with the blood supply of the motor area above the speech 
centre on the left side. I expressed the opinion that Mr. X. 
had atheromatous cerebral arteries, and that the terminal 
branches of the left Sylvian artery were blockaded. I antici- 
pated gradually increasing hemiplegia. 

I did not again see the patient alive, and I am indebted to 
Dr. Abbe for notes. 

On September 20th, contracture of the left forearm and hand 
appeared, both arms being similarly stiff and semiflexed ; they 
were occasionally drawn up by spasm. Vomited. 

Sept. 22. — Increased drowsiness ; both arms contractured, 
complains of head feeling hot inside (cool outside). Lucid 
intervals. No anaesthesia. Temperature in axilla 38.1° C. ; 
pulse, 110. 

During the last thirty-six hours of life the symptoms were 
profound drowsiness, absolute loss of vision. He occasionally 
whispered, and when asked if he heard what was said about 
him, said yes. 

It is now stated that on September 18th (the day before I 
saw Mr. X.) he used the wrong words a few times, saying, for 
example, "diasnosis" for "diagnosis," etc. Mental action 
remained clear, but slow, until the last few days, when deep coma 
set in. During the last three or four days of life (even while 
27 



418 CEREBRAL HEMORRHAGIC PACHYMENINGITIS. 

some consciousness remained), sight was lost. To the very last 
of life the pupils were small and fixed. The pulse was abnor- 
mally full and slow from the onset of the disease (I found it tense), 
beating regularly from 58 to 60 a minute. At the time of con- 
sultation, six days before death, it was higher, nearly 80, and 
rose to 110 or more in the last three days. Slight fever was 
observed in the last few days. 

The patient lived perhaps one month after the onset of the 
peculiar cephalalgia. 

Sspt. 25. — Died comatose. 

Autopsy made 24 hours post mortem. Head only examined. 
While removing the calvarium two unusual phenomena occurred. 
When the sawing was nearly done a small hole was made in one 
temporal region through the dura mater, and from this, through 
the line of sawing a fine jet of dark blood came out with extra- 
ordinary force, not per saltum. When the skull cap was torn 
off (with great effort, as the dura was closely adherent to the 
calvarium), the dura gave way in the frontal region, and a per- 
fect torrent of dark liquid was forced upward and backward, 
drenching the operator, striking his face, and some of it reach- 
ing three or four feet behind the head upon the floor. No one 
present (Drs. Herrick, Abbe, Amidon, and myself) had ever 
witnessed such an occurrence. 

It was soon seen that this escape of liquid blood was from the 
cavity of an immense double haematoma ; a large amount of 
fluid blood and some sheet-like clots lay in cavities formed ex- 
ternally by the dura mater and internally by a false membrane, 
united at its margins to the dura. There were thus two sacs ex- 
tending over almost the whole of the superior and lateral aspects 
of the cerebrum. These sacs extended from the outer border 
of the anterior fossae to the tentorium cerebelli, being thickest 
at about their middle, i.e., over the fissures of Rolando and 
Sylvius, and the adjacent motor convolutions, thinning off in all 
directions. It seemed to me that there was but a thin sheet of 
clot and membrane over the posterior part of the third frontal 
convolution on either side. Judging from the violent irruption 
of blood which occurred on opening the skull, it seems evident 
that the liquid blood in the sac must have been under enormous 
pressure. 

Another proof of this lay in the remarkable deformity which 
the cerebrum presented, the hemispheres in their upper median 



INTRA-BUCCAL FARADIZATION. 419 

regions being concave instead of convex. The greatest depres- 
sion below the normal level of the convolutions was estimated by 
those present at about 18 mm. The excitable districts on both 
sides — the centres for the forearm and leg, according to physi- 
ologists — were the seat of greatest depression. The speech 
centre seems to have escaped direct compression. The arteries 
at the base of the brain and in the fissures of Sylvius were 
normal. The arachnoid and pia were everywhere healthy ; not 
opaque or adherent to the false membrane. The brain was not 
cut, as I desired to preserve the cerebral deformity which for 
an hour did not vary. In hardening, the whole brain was some- 
what distorted and the depression made to seem less. 



THE INTKA-BUCCAL METHOD OF FARADIZEN T G THE 
LOWER FACIAL MUSCLES.* 

In the last two or three years I have used a ready method of 
applying electricity to the lower facial muscles, which has not, I 
believe, been generally known or employed. . The method is 
based upon several facts : (1) that the inferior facial muscles 
present well-defined motor points upon the buccal mucous mem- 
brane ; (2) owing to the constant moisture of the mucous mem- 
brane, the application of a strong current is well borne ; (3) that, 
in consequence, a better contraction is obtained by a given 
strength of current applied in this w T ay, than when it is applied 
percutaneously. 

It would be tiresome to enumerate the muscles which can thus 
be made to contract in a most complete way ; suffice it to say, 
that all the muscles below the malar bones and the nose can 
thus be reached. A good reaction of the masseters may be 
obtained. 

The instrument which I employ is figured in the annexed 
wood-cut. It consists of an ordinary interrupting handle, armed 
with a rod-like electrode of moderate length (10 cm. or more), 
bent at right angles near its extremity, and terminating in a ball 
5 mm. in diameter. The whole of the rod or stem, except the 
ball, should be completely insulated. 

The indifferent electrode (sponge) may be placed in one of the 

* Reprinted from the Archives of Medicine, vol. iv., No, 1, February, 1880. 



420 INTRA-BUCCAL FARADIZATION. 

patient's hands, upon the back of his neck, or over the trunk of 
the facial nerve. 

The same special electrode will serve to make applications to 
the pharyngeal and palatal muscles. 



By this method I ha^e been able, in the stage of recovery of 
rheumatic facial paralysis, to obtain distinct contractions with 
faradism, when the strongest currents which could be tolerated 
on the skin of the face did not produce them. 



ON THE COINCIDENCE OF OPTIC NEUEITIS AND 
SUBACUTE TKANSVEESE MYELITIS.* 

Mr. President and Gentlemen : — For nearly thirty years, since 
the first researches of Budge and Waller, of Claude Bernard and 
of Brown-Sequard, on the spinal innervation of the eyeball, 
physicians have been acquainted with various ocular symptoms 
of spinal diseases. The more prominent of these associations 
have been the myosis and atrophy of the optic nerves observed 
in the course of sclerosis of the posterior columns of the spinal 
cord, or progressive locomotor ataxia. Again, myelitis of the 
cervical spinal cord, whether inflammatory or from compression 
(Pott's disease, tumors, etc.), has been known to cause variable 
states of the pupil, due to irritation or destruction of the cilio- 
spinal centre, so-called, a region of* anterior gray matter extend- 
ing from the level of the fifth or sixth cervical nerve to that of 
the third or fourth dorsal nerve. 

But the literature of spinal affections has been searched in 
vain for an example of transverse myelitis associated with an 
acute affection of the optic nerve. All of the recorded changes 
in the optic nerves in the course of spinal affection, were of a 
chronic and degenerative kind. 

In the last year three instances of the remarkable coincidence 
of optic neuritis and transverse myelitis have occurred, and I 
thought it might prove interesting to lay them before you. 

Although two or three cases had been observed and recognized 
by me before reading an account of the third, I think it but 
right to place this first in order of relation, because it was the first 
published. The observation is by the distinguished neurologist, 
Dr. W. Erb, now Professor in the University of Leipzig. His 
paper was read on May 17, 1879, at the fourth meeting of the 
Neurologists and Alienists of Southwestern Germany, held at 
Heidelberg ; and it was published later in the autumn in West- 
plied' 's ArchivA 

* Reprinted from the Journal of Nervous and Mental Disease, April, 1880. 
Read before the New York Neurological Society, March 2d, 1880. 

f W. Erb. — "Ueber das Zusammenvorkommen von Neuritis Optica und Mye- 
litis Subacuta." — Arch. /. Psych, und NervenJcrankheiten. Band x., Heft i., 
p. 146, 1880. 



422 OP L1C NEURITIS AND MYELITIS. 

Case I., by Prof. Erb. — I was consulted, on July 18, 1877, by a man aged 
52 years, who, previous to the present illness, had enjoyed good health, and 
had never had syphilis. He had experienced a combination of rapidly devel- 
oped and peculiar blindness with alarming paralytic phenomena. 

The following is a history of the case : In February, 1877, the left eye 
became suddenly affected ; diminished vision : central scotoma, and in a few 
days total amaurosis ; and after a few weeks return of vision. The ophthal- 
moscopic examination was negative. Soon afterward the right eye was simi- 
larly affected. Blindness followed by recovery, negative results to ophthalmo- 
scope. The beginning of the illness was marked by slight headache.* 

After a while there was still another attack ; this time in both eyes, com- 
mencing with bitemporal hemiopia and color-blindness ; progressing rapidly 
to complete blindness. On this occasion the ophthalmoscope revealed a well- 
marked optic neuritis, with some distinct atrophy. At no time was there 
choked disk. 

In the last few weeks improvement has once more shown itself. The patient 
can now read Jager No. 4 ; distinguishes the outlines and colors of objects, 
but cannot yet recognize faces. • 

The treatment consisted in seventy-six inunctions with unguent, hydrar- 
gyri cinereum, local abstraction of blood, purgatives, and a seton in the 
neck. 

During the three or four weeks preceding the consultation, there had oc- 
curred drawing and tearing pains in the legs, trunk, and in the lower thoracic 
regions (cincture pain); there was but little pain in the arms. In the course 
of fourteen days the following phenomena were added : Rapidly increasing 
weakness of the rigid leg, which soon became completely paralyzed, and at 
the same time anaesthesia of the left leg. Later still the left leg also became 
weak. Associated with these symptoms were retention of urine, later incon- 
tinence (now present) and anaesthesia of the urethra and rectum. 

Examination on July 18. — The patient is a strong, healthy-looking man. 
He has slight fever (38.5° C); amblyopia of both eyes; pupils and movements 
of the eyeballs are normal. The other special senses are normal. Memory 
and intelligence preserved; no headache or vertigo. 

The upper extremities present no symptoms. The right hand is often the 
seat of slight pain, but there are no paresthesia? or disorders of motility. 

The right lower extremity is entirely paralyzed, and the left thigh, though 
paretic, can be moved in all directions; the muscles of the abdomen and back 
are very weak. 

The sensibility of the right leg is generally preserved, though in a few 

* The ophthalmic notes concerning the first stages of the disease, including the 
three distinct attacks of blindness, are by Dr. Steffan, of Frankfort-on-Main. 
These notes differ from Dr. Erb's summary in the important particular that in 
the first two attacks (each optic nerve alternately) a slight optic neuritis, oedema 
of edges, without swelling, was seen with the ophthalmoscope. Besides, some 
interesting limitations of the field of vision were noted. 

Dr. Steffan will publish a full account of the eye symptoms in this interesting 
case. 



OPTIC NEURITIS AND MYELITIS. 423 

places it is diminished. The right half of the abdomen is evidently hyperaes- 
thetic, as is a region round about the thorax at the level of the nipples. The 
left lower extremity and the left half of the abdomen are very distinctly anaes- 
thetic ; the left side of the back is anaesthetic, the right sensitive. These are the 
unmistakable signs of a lesion involving one lateral half of the spinal cord, as 
given by Brown-Sequard. The lower dorsal region is the seat of some pain ; 
no spinal tenderness, or deformity, or stiffness. 

The cutaneous and tendon reflexes in the legs are increased ; reflex move- 
ment of abdominal muscles not present. 

No atrophy or bed-sore. There is paralysis of the bladder; there is occa- 
sionally involuntary evacuation of urine; the patient is constipated, and he is 
not fully conscious of the passage of faeces. 

Prescription. — Cold compresses, according to Priessnitz's method, to the 
spine; every three days dry cups along the vertebral column; iodide of potas- 
sium; extreme cleanliness, and attention to bowels. 

July 27. — In the last few days signs of acute cystitis; bowels distended 
with gas; from time to time the legs jerk. Other symptoms not much 
changed. The right lower extremity is still completely paralyzed, the left a 
little weak. . Sensibility very slightly diminished on the right side; there is 
no longer any hyper aesthesia; the cincture feeling is gone; the right half of 
the abdomen shows muscular tension. Plantar reflex and the tendon reflexes 
are greatly increased; dorsal clonus is easily produced. No bed-sore; eyes as 
before. 

In the next few days, probably in consequence of the cystitis, there were 
several chills, and the temperature rose to 40.3° C. 

In the next few days improvement began, and the following is noted on 
August 11: The left leg once more possesses all its movements and is quite 
strong; the right lower extremity is also movable, but is weaker than the left. 
There is hardly a trace of the alteration of sensibility; there are next to no 
pains in the legs. Reflexes less marked; bladder and rectum unchanged ; eyes 
in statu quo. The patient's general condition is much better. Ordered same 
treatment, except that the iodide of potassium is omitted, and a little mor- 
phine given for insomnia. 

Progressive improvement took place, so that on September 28th it is noted 
that the legs are strong enough to enable patient to take a few steps (no 
ataxia); the sensibility is normal, and the bladder acts well. At times he has 
a sense of tension in the back, and an occasional pain in the legs. The eyes 
have improved a little. 

Toward the close of the year the patient's objective symptoms were about 
gone ; the reflexes were still strong, but he complains of various paraesthesiae 
in the legs, a ''ringing" or vibration while sitting, sensations of weight and 
of swelling. 

In the spring of 1878 the patient was well, except that he had sensations 
of slight heat and crawling in the legs and back. 

From November 12, 1878, to March, 1879, the patient had a galvanic treat- 
ment for his eyes, with marked improvement. 

Dr. O. Becker of Heidelberg, found the following: Slight myopia of both 
eyes ; pupils rather small, acting well. R. V. fa 



424 OPTIC NEURITIS AND MYELITIS. 

at 6 metres, with -f- 3 R. V. Jager No. 3. L. Y. No. 6. Both eyes are blind 
for green and red. 

The ophthalmoscope shows atrophy of the optic nerves, with slight excava- 
tion; nerves bluish. Lesion more marked on left visual field, slightly reduced 
concentrically; no scotoma. 

" At the close of treatment, March 4, 1879. R. V. -l=J^ igf L. Y. - 1 = 
"A" 18' w ^ +^' can reac ^ -^°' ^ J^o er an( l make out a few words of No. 2; 
with -j- 4 and -f- 5 can read newspaper print easily. 

Case IL— Drs. H. D. Noyes and T. A. McBride. On September 5, 1879, I 
saw Mr. D., a patient of Dr. H. D. Noyes, at the request of Dr. T. A. Mc 
Bride. Dr. McBride has already made an exhaustive examination of the case, 
and the following is a history based upon a memorandum which he sent 
with the patient. I desire to express my thanks to Dr. Noyes and Dr. Mc- 
Bride for permission to make use of the case. Mr. D., a clerk, aged twenty- 
five years, suffered from debility during the whole of the past summer. Since 
March has had several "-bilious attacks." 

On August 9, was seized with severe diffused headache, which lasted day 
and night for a week. Was constipated and nauseated. No headache since. 

August 18, retention of urine occurred, for which the catheter was used 
three or four times in the course of ten days. The bladder has been sluggish 
since. During the same period (last two weeks of August) patient noticed 
stiffness and pain in the muscles of the back, preventing his bending forward. 
The pain was in the lower dorsal region. In the kst ten days no pain, but a 
sense of numbness and anaesthesia has appeared in all parts below the waist. 
The loss of sensibility was discovered in the bath; he did not feel the contact 
of water normally. About the same time (ten days ago) he also noticed a 
dimness of vision, which has since increased almost to blindness, at times. 
No symptoms in upper extremities. Patient denies syphilis, or injury to the 
head and spine. Several members of his family have died of phthisis. Ex- 
amination: walks well; no disturbance of equilibrium, or inco-ordination. 
Dynamometer shows in right hand, 65, 63, 65; in left, 60, 56, 61 (weak in- 
strument). No actual paresis of the lower extremities. Knee tendon reflex 
normal. Sole reflex deficient, especially on the right side. Sensibility is 
much impaired below the waist. Touch is badly perceived (an oesthesiometer 
point seems like a finger), and pricking or pinching still less. There is, con- 
sequently, more analgesia than anaesthesia. At times the legs tremble ; no 
spasm, or formication. Sight is very defective, the fields of vision are irregu- 
larly limited, there is marked loss of color perception. The ophthalmoscope 
shows typical choked disk on both sides. The temperature in the mouth is 
37.9° C. The heart is normal; percussion of skull and vertebrae produces no 
pain. 

The above was Dr. McBride's examination. My own gave corroborative 
results, viz. : a paraplegiform anaesthesia (incomplete), and double neuro- 
retinitis. The latter lesion seemed less than as described by Dr. McBride, 
and vision less impaired; he could count fingers and trace features easily. 

My diagnosis was double lesion, one at the base of the brain, involving the 
optic nerves and the chiasm, and a focus of myelitis in the centre of the cord 



OPTIC NEURITIS AND MYELITIS. 425 

in its low dorsal region. I advised a continuance of the iodide of potassium 
in full doses. 

[The following are additional notes furnished by Dr. Noyes. Dr. Noyes 
took part in the di'^ussion on this paper, and exhibited to the Society dia- 
grams illustrating the extraordinary changes in the fields of vision- in his 
patient. ] 

"Vision became impaired at the same time that the bladder trouble came 
on. No phosphenes; no tenderness over lower portion of spinal column. 

"September 2d. — The field of vision, O. S., normal. O. D. : Perception 
absent on nasal side, encroaching centrally beyond the median line, with con- 
traction of the peripheral portion in other localities. Ophthalmoscope shows, 
O. D., the inner half of disk is most swollen — there is a small segment down- 
wards and outwards, which is not much affected. It looks more like a 
neuritis descendens than a true choked disk. Not much choking of left 
disk. O. D. H = 2.2. 

"The patient was next seen September 6th. — The condition of fields of 
vision being much the same, except that the sight has improved. Sight re- 
turning in the infero-nasal quadrant. O. S. normal. 

" September 11. — To-day, for the first time, find that the left eye on the outer 
has lost its perceptive power almost entirely, there being only a small ovoid 
spot on the horizontal meridian where perception remains. The right now 
shows that the field is changed from the showing on the Gth, and things are 
reversed — seeing now only in the nasal quadrant. The patient feels satisfied 
that September 8th the change began for the worse in his left eye — at the 
same time that his right eye had changed as to field, viz., seeing only in the 
infero-nasal quadrant. The inner half of the right optic disk is swollen — the 
vessels are tortuous — the outer half is pale. The inner half of the left disk is 
swollen, the same as the right, the outer half being pale. 

"September 16th. — His sight, in his own opinion, has not altered much. 
Examination shows recovery of a considerable amount of his lost fields of 
vision — the right being normal except for the presence of a scotoma; while the 
left shows the previously mentioned oval area of perception lower in the tem- 
poral portion of the field to have increased considerably in size ; otherwise the 
field in O. S. is similar to last entry. 

"September 20th. — Fields of vision have improved, there being only a cen- 
tral scotoma, of small size, in each field of vision. The sight is better, but it 
is not possible to measure it accurately. Both disks are in parts swollen, but 
not so much as at last examination — yet plainly to be seen still. There is an 
unusual pallor of other parts of the disks, that were at the earlier stages 
swollen. 

"September 26th. — Patient says that his sight was much better yesterday 
than it has been for some time. His fields have not altered — the scotomata 
being still present. The color perception is poor. He recognizes blue and 
most of its shades. Red is recognized next. Gray, violet and green are 
mistaken. 

" October 4th.— V = 7 6 - O. S. 

" October 14th.— O. D. V. = 2Uo. O. S. V. = 6 fi . Cannot find positively any 



426 OPTIC NEURITIS AND MYELITIS. 

true scotoma in either eye. There is a certain amount of dullness of percep- 
tion over the small scotomata found at the last examination. 

" October 21st.— O. D. V. = fa. O. S. V. = -fa. 

" October 30th.— O. D. V. = fa. O. S. V. =± fa. Inner half of both disks 
swollen — the outer pale. 

"December 20th. — Y. = - 2 e -. O. D. No scotoma — color perception good. 
Fields of vision perfect for both objective and color tests. 

"January 24th, 1880. — V. = fa in each eye. Fields for objective and color 
tests normal." 

The paraplegia had long since disappeared. 

Case III. — Personal. — Shortly before reading Prof. Erb's 
paper, I had the opportunity of seeing the following interesting 
case, and of treating it. The patient was originally under the 
care of Prof. Willard Parker, who, on December 9, 1879, trans- 
ferred the case to me. 

J. P. M., a banker, aged 35 years, had enjoyed excellent health for many 
years, and had never contracted syphilis. For some time previous to the de- 
velopment of the present illness he was in business in Virginia City, Nevada, 
at an altitude of more than 7, 000 feet. 

On September 5, 1879, he first noticed numbness in his feet and legs, but 
was perfectly able to walk. This numbness was stationary for three or four 
days; then a feeling was noticed as if there were an iron bar or block in the 
perineum; the legs became noticeably weak about the 28th. Mr. M. came 
east by way of Panama, and while on board the ship he used his legs actively. 
Arrived in New York in the first week of October ; he could still walk to 
his meals in the hotel, though he dragged his feet — the right more. The 
numbness continued. He suffered a "distress" in the sacrum, but had no 
pain in back or legs. After a week, during which he exerted himself a good 
deal, the paralysis increased, and he ceased walking; sensibility became im- 
paired. For a fortnight (middle of October) there was absolute loss of 
motility below the waist and much anaesthesia, though he never lost his feet 
in bed. At one time he had the feeling of numbness as high as the groins. 

Sensation and motion returned in the left leg first ; and since the end of 
October both legs have gradually but steadily improved. He can now move 
every joint in the lower extremities, but he has not yet tried to stand or walk. 
He has had a band-like feeling around the calves of his legs, and a pressure 
feeling in front of the abdomen. He never had retention of urine, but at 
times involuntary squirts. Was greatly constipated. There have been no 
active symptoms in the arms, but it was noticeable that if placed in an awk- 
ward position they easily became numb. The paralyzed muscles did not 
waste, no bed-sores formed, and the general health remained good. During 
the period of convalescence Mr. M. noticed severe tonic amd clonic spasms in 
the legs ; less lately. 

During the past two weeks blurred vision of the right eye has been noticed. 
This was preceded one week by severe pain in the right orbit and near the 



OPTIC NEURITIS AND MYELITIS. 427 

brow. Lately sensibility has greatly improved ; a little tight feeling remains 
around the insteps. 

Examination. — Patient is surprised to find that he can stand. Closing eyes 
does not impair equilibrium. The legs are weak, but every muscle and articu- 
lation can be moved. The reflex at knee and sole is exaggerated. Sensibility 
is'normal to touch and pinching; localizes impressions correctly. No ataxia-, 
the muscles are well nourished ; spine not tender ; erections (absent for a time) 
are returning. 

Treatment was begun only at the time when paralysis became marked, 
seven or eight weeks ago. He was then given moderate doses of iodide of 
potassium, .002 of strychnia three times a day, and he was rubbed. 

December loth. — At my request Dr. Arthur Mathewson, of Brooklyn, saw 
the patient and examined his eyes. The following are Dr. Mathewson's notes : 
"On first examination the nerve of the right eye was found whitish and 
oedematous, with outlines rather indistinct; vessels only slightly tortuous, veins 
full and dark (in both eyes); media clear; refraction nearly emmetropic, but 
the most prominent part of the nerve disk was in focus with a +2.2. 
Vision was not tested accurately for want of means at patient's house, but 
he could read about Jager No. 10 with the affected eye. There was also a 
slight lateral tremulous motion of the right eye, a sort of nystagmus." 

These two examinations justified the diagnosis of sub-acute transverse 
myelitis in the lower dorsal region, with optic neuritis limited to one eye. 

I will not weary the Society with a transcript of my full notes 
of the further progress of the case. Suffice it to say that im- 
provement in vision and in the power of walking, with decrease 
of reflexes, occurred, until at the present time the patient is 
nearly well. The treatment consisted in the withdrawal of the 
strychnia ; the gradual increase of the iodide of potassium up 
to more than four grams three times a day, galvanism to the 
spine and muscles, and massage. 

Dr. L. C. Gray, of Brooklyn, had the immediate management 
of the case, and I saw the patient nearly once a week. In Janu- 
ary there was added to the above treatment an evening dose of 
two grams each of fluid extract of ergot and bromide of potas- 
sium, which had the desired effect of lessening the reflexes. On 
February 20th Mr. M. came to New York to see me. His gait 
was quite normal ; the knee tendon reflex rather strong (no 
spontaneous reflex movements) ; he complained of only a trace 
of numbish sensation in the calves and in the nates ; in walking 
a slight sense of constriction is experienced upon each leg below 
the knee, on the inner side. Vision of right eye is nearly nor- 
mal ; the nerve is whitish, "" the nystagmus (horizontal) is still 
present. 



428 OPTIC NEURITIS AND MYELITIS. 

March 1. — Dr. Mathewson has kindly sent me the following 
memorandum : "I have just carefully examined Mr. M.'s eyes 
as they stand to-day, and send you the result. There is now no 
limitation of the fields of vision, and no scotomata, and there is 
no marked diminution of color perception. The oedema of the 
nerve of the right eye has now wholly passed away, so that 
its outlines are perfectly distinct, and the disk is paler than nor- 
mal, and quite in contrast with the nerve of the other eye, 
which is rather hypersemic, with outlines not quite well defined. 
There is a manifest hypermetropia, of 1.5 (by ophthalmoscope 
1.5 +) of the right eye, its vision is ■£»> while the left is nearly 
emmetropic and has perfect vision also. There is still a slight 
trace of the nystagmic movement, though it is not constant." 

The optic neuritis in this case was intermediate in type be- 
tween the conditions observed in the two other cases. There 
was oedema of the periphery of the nerve with some swelling of 
the disk — a degree of choked disk. This was followed by 
atrophy without marked loss of vision. All the morbid proc- 
esses occurred in one eye. 

It is interesting to note that the distribution of the inflammatory 
lesions varied in each case within very considerable limits. In 
the eyes it affected alternately each optic nerve, and both at one 
time in two cases. In Dr. Noyes' case the changes in the fields 
of vision were singularly capricious. In the third case only one 
optic nerve was affected. These irregularities and the peculiar 
symptoms of bitemporal hemiopia (in Case I.) are, it seems to 
me, explicable only upon the supposition of a lesion at the base 
of the brain involving the chiasm and optic nerves. The phe- 
nomena in the third case (symptoms in one eye only) would 
seem to exclude most positively a cBntral cerebral lesion. 

In the spinal cord the inflammatory changes were in the dorsal 
region in all the cases, but in all other respects there were 
marked differences. 

In Case I. the right half of the spinal cord no doubt contained 
most of the lesions. 

In Case II. the sesthesodic region of the cord (posterior gray 
matter or peri-ependymal region ?) was chiefly involved. 

In Case HI. the entire structure of the cord must have been 
slightly affected, the motor region most. The comparative 
escape of the bladder in Case III. (no retention) is instructive 
anatomically, as the limitation of the numbness to the altitude 



A CASE OF MTSOPHOBIA. 429 

of the groin would indicate that the lesion was in the lowest 
dorsal or upper lumbar region of the cord, below the vesical 
centre. In Cases I. and III., where the limits of numbness and 
the constriction band indicated disease of the mid-dorsal por- 
tion of the cord, retention and cystitis occurred. 

The question naturally arises : Is there any causal or phys- 
iological relation between the two sets of phenomena observed 
in these three cases ? 

Prof. Erb answers in the negative, and it seems to me that 
with our present knowledge of the relations between the optic 
apparatus and the spinal cord we must, in agreement with him, 
consider this association of optic neuritis and transverse mye- 
litis as accidental. 



A CASE OF MYSOPHOBIA.* 

Miss X., aged 18 years, consulted me on January 30th, 1880, 
for a peculiar form of nervousness. 

From the patient's mother I obtained the following history of 
the case. Childhood and girlhood had been healthy ; menstru- 
ation began in the twelfth year, and has since been normal and 
regular. Patient has led an idle, luxurious life, doing as she 
pleased and taking a few private lessons at home. Has been 
allowed to rise at 8 or 9 a.m., to lounge about and read trashy 
novels. Was of a bright, happy temperament. The occurrence 
of insanity in the family is denied, though maternal grandmother 
had senile dementia, and one brother had fits at six months, 
followed by hemiplegia, epilepsy and imbecility. As bearing on 
the case it must be mentioned that patient's grand-uncle died of 
" cancer of the nose." 

About three years ago patient had a moderate leucorrhcea, 
relieved by a tonic course. After this, was observed to droop 
and look tired, and she began to entertain the hypochondriacal 
fear or delusion that she too had or was to have cancer of the 
nose. (It was not till last summer that she confessed this notion, 
which was the cause of her inexplicable melancholia.) Ever 
since, Miss X. has been the victim of extreme hypochondriasis 
and mysophobia. The hypochondriasis consisted exclusively in 
fear of internal nasal cancer, and many of her first peculiarities, 

* Reprinted from the Archives of Medicine, vol. iv., No. 1, August, 1880. 



430 A CASE OF MYSOPHOBIA. 

as to washing herself and fear of contamination, were logically- 
related to this idea ; she fussed with her hair, face and hands, 
in order to prevent others from catching the cancer which 
she had. 

It is useless to relate all the details of the morbid cleanliness 
of the patient. She would wash her hands every five minutes, 
and wipe each finger carefully and long. She would spend an 
hour or more in the bath-room, and use a dozen or more towels 
for her morning toilet. She would spend an hour or more in 
combing and brushing her hair. Great slowness in all acts is 
observed. Avoids touching door-knobs, plates, chairs, etc., 
without protecting her hand by a glove or a fold of her dress ; 
refuses to pass dishes, etc., to others at table ; will re-arrange a 
chair several times ; has been seen to approach a door and 
retreat several times before passing through it ; has stood in 
the middle of the room with an absurd automatic pendulum 
movement of whole body or of one arm ; is reluctant to wear 
clothing, especially under-clothing, more than a day at a time. 

Has bad, restless nights ; at times is rather excited, and will 
pace up and down a room ; usually inert, lies on a lounge with a 
novel ; has seemed as intelligent as ever ; at times pain in head 
and in mid-dorsal region ; no hysteria or agoraphobia, or 
delusions of any other sort than the above. 

The examination is nearly negative. Miss X. presents the 
appearance of health, and is rational. She admits the absurdity 
of her freaks and notions, blushes and attempts to hush her 
mother in the relation of details. Even as regards the original 
hypochondriacal notion of cancer in the nose she is not firm, 
having nearly lost her belief in that disease since a thorough 
examination of the nose and throat was made by a specialist 
some months ago. Explains her actions by her desire that no 
one should acquire the cancer from her. Hands are chapped by 
constant wetting ; spine not tender; tongue clean; heart normal 
and pulse good. Has a semi-melancholic rather dull look, and 
eyes easily fill with tears. Denies masturbation. 

I carefully laid out a plan of moral treatment, by which she 
was to be gradually and firmly prevented from doing her strange 
acts. She was ordered long walks and a little study. Every one 
near her was instructed to assume a semi-imperative tone and 
manner toward her. She was to clean her own room. 

I decided to try a course of treatment by narcotics, similar to 



A CASE OF MYSOPHOBIA. 431 

that which succeeds so well in mild melancholia. She was 
given extracts of opium and cannabis indica with a little 
rhubarb. February 24th great improvement is reported ; patient 
has gained self-control and is cheerful ; sleeps well. On account 
of nausea, the opium was omitted, and a pill of cannabis indica, 
reduced iron and rhubarb ordered. At bed- time 1.5 gm. of 
bromide of potassium. March 15th : Has been in the country 
two weeks, taking above remedies and walking a great deal. Is 
well. Advice : discontinue medicine, but occupations to be 
increased, exercise to be continued, and a firm moral hold to be 
kept on the patient. 

I should add that Miss X. was not allowed to know the nature 
of her medicines. 

While recording the case of this singular form of hypochon- 
driasis, I desire to express my belief that a relapse, or the 
development of a different or more serious psychosis in the 
patient is very probable. 

Mysophobia was first described and discussed by Dr. William 
A. Hammond, in Neurological Contributions, Yol. I., No. 1, 
p. 40. N. Y., 1879. 



ON OCCIPITAL HEADACHE AS A SYMPTOM OF 

UK^MIA.* 

I have recently met with, two cases in which occipital headache 
was so localized and persistent as to give rise to a strong suspi- 
cion of organic disease of the cerebellum, and in one of them a 
positive conclusion was only reached by means of a post-mortem 
examination. These cases both now appear to have been cases 
of contracted kidneys and uraemia. 

I shall first relate the cases as they are in my case-book. 

Case I. — Lieut. X., U. S. A,, aged thirty-six years, consulted rue on No- 
vember 5, 1879, and gave the following history: Until the time of his gradua- 
tion from West Point he had suffered from frequent general headaches ; but 
that since leaving the school in 1867 he had several severe attacks of occipital 
headache. These at first occurred two or three times a year, but in the last 
few years much more often, the attacks lasting from twenty-four to forty- 
eight hours, accompanied by vomiting and sometimes by delirium. These 
paroxysms were often relieved by bromide of potassium. In 1876, during 
Centennial times, he had one of his headaches, and with it an epilepti- 
form convulsion, in which he did not bite his tongue. In February, 1879, at 
the same time with a headache, he had another convulsion, in which the 
tongue was bitten. He has noticed that w r hile in the Northern States he ha3 
but few headaches, whereas when in Texas he has had a great many. He 
often had a feeling of soreness and fullness in the back of the neck, and is 
very nervous after the attacks; has been in the North since March. In August' 
had a severe attack and another on October 26, aborted by bromide of potas- 
sium. This last headache was accompanied by stiffness and fullness in the 
back part of the neck. There are no special ocular symptoms during the 
attacks, and he considers his eyesight normal. During the paroxysms the 
face is flushed, the head feels full and pulsating. The father and the grand- 
father of the patient had sick-headache. 

Mr. X. has abstained from the use of intoxicating drinks since 1876 ; he 
has never been injured about the head, and has never had syphilis. 

Examination — Eyesight normal to all ordinary tests; no astigmatism; no 
lesion seen with the ophthalmoscope. Cervical spine not lender; no symp- 
toms of dyspepsia; heart normal. The general appearance is that of health. 
November 6th, looks puffy under the eyes. Three specimens of urine are 
examined with the following results : Their specific gravity is low, ranging 

* Eeprinted from the Archives of Medicine, Vol. iv., No. 1, August, 1880. 



OCCIPITAL HEADACHE IN URAEMIA. 433 

from 1,018 to 1,020 ; they all contain albumen — from. 1 per cent, to .5 per cent., 
and hyaline casts. The retina? are re-examined with negative results. Subse- 
quently, numerous examinations of trie urine were made by Dr. Alexander, 
Surgeon U. S. A. at TVest Point, and evidences of chronic Bright's disease 
were invariably found, such as low specific gravity, hyaline and granular 
casts ; the amount of urea in one period of twenty-four hours was about twelve 
grammes. 

Case II. — Mr. J. AV.. a merchant, aged 47 years, was seen by me at Passaic, 
K. J., in consultation with Dr. J. C. Herrick, on December 21, 1879. I ob- 
tained the following history of the case : 

The patient had formerly enjoyed good health; had never received any in- 
jury to the head : no syphilis. During all his adult life he has suffered from 
headaches, more or less periodical, perhaps one in three weeks, each attack 
accompanied by nausea, and usually lasting one day. Of late years he has 
had much less of this headache ; it was evidently migraine. About twelve 
years ago, in the streets of Xew York, during hot weather, he had an attack 
which was called " sunstroke. "' The symptoms of this attack are unknown. 
Mr. "W. consulted me in 1874, but I have no notes of his case except a memo- 
randum of my examination of the urine. This appears to have been perfectly 
normal. 

In the last two years he has been almost constantly suffering from some 
headache, a little every morning, and more and more often of late he has had 
severe attacks. In the past two months very severe headaches, with nausea 
and vomiting several tiijies a week. During the last two wejeks has been 
confined to his bed. The patient and his wife clearly distinguish this pain 
from the former headaches by several characteristics; the pain is more violent, 
it is distinctly occipital, and lately has been cervical as well; it appears in par- 
oxysms at any time, chiefly during the day, and the pain itself is of a different 
character. After a migraine Mr. W. felt very well ; but now after a severe 
headache he is prostrated and dull. The nausea always comes on after the 
pain : he has no nausea between the paroxysms. He has not had much frontal 
headache, but the pain has extended from the occiput into the vertex and the 
whole top of the head. Movements aggravate the pain. There is no affec- 
tion of sight or hearing; no dizziness. Of late has needed morphia; Paul- 
linia seemed effectual for a few days only. During the last week he has 
taken about 4 gm. of bromide of potassium a day, and on the clay before yes- 
terday he had 15 gm. in twenty-four hours. The attending physician has 
examined one specimen of urine, but found no albumen. 

Examination.— Patient feeble; lies relaxed in bed; voice faint, but articula- 
tion is distinct; mind clear; the head is not tender. The right eyelid is in 
partial ptosis; no strabismus; the ophthalmoscope shows no lesion of the 
fundus f atropine used). The right side of the face is rather inert, but the 
tongue (heavily coated) points straight. The'hands are of due proportionate 
strength: in walking the right foot is dragged after a few turns in the room. 
No incontinence of urine ; morphia affects patient very readily ; he has had 
none in twenty-three hours, yet he is dull, and his pupils are small and fixed. 
The heart is normal, but the pulse is quite irregular, beating 23 and 29 in 
successive thirds of a minute; twice in the minute an acceleration is noticed 
28 



434 OCCIPITAL HEADACHE IN UREMIA. 

There is a trace of oedema on the tibias. Patient denies that his neck is 
really stiff, though he carries his head on one side, and keeps it quite still; no 
opisthotonus. To-day the pain extends to the sixth cervical vertebra. 

I declined to give a positive diagnosis until after the urine had been thor- 
oughly examined. At the same time I saw that the patient was in great dan- 
ger from exhaustion and a tendency to stupor; and that many of the symp- 
toms of tumor in the cerebellum were present. One was lacking, viz. : neuro- 
retinitis. I also thought he was brominized. 

On December 23, three specimens of urine were received, and were at once 
examined by Dr. R. W. Amidon. The specific gravity was found to vary be- 
tween 1,024 and 1,025 ; there was albumen in all, varying in amount from 3 to 
10 per cent. ; there were also in all specimens numerous hyaline and grauular 
casts. 

Mr. W. died on December 27th, in a comatose state ; no convulsions or fur- 
ther paralytic symptoms having shown themselves. The autopsy, made on 
the 28th, showed that the cerebellum and the other parts of the encephalic 
mass were normal ; while both kidneys were extensively diseased. The left 
kidney was found completely diseased, granular and hard in places; its mem- 
branes peeling off with difficulty. It had a reddened congested appearance, 
and showed some evidences of not only a chronic trouble, but of a more 
recent acute inflammatory action. The right kidney was found to be only 
partially affected; somewhat congested, and with the same type of lesion. 

Dr. Herrick, to whose courtesy I am indebted for the above account of the 
autopsy, adds: "The results of our examination go to show evidently that, 
after all, the patient's symptoms may have originated from a renal disease, 
although we cannot explain yet why his headaches so many years should have 
been from such a cause. He had never complained of back-ache or of any of 
the usual symptoms of Bright's disease, excej^t the head pain." 

The following is a summary of the symptomatology of the two 
cases : 

Both patients were adults ; both had suffered from chronic 
headache more or less of the migraine type ; at a given period 
the headache became transformed into a localized occipital pain, 
very different from that of the former attacks. 

In Case II., the pain extended down the cervical spine, and was 
so much aggravated by movement as to suggest a rigid state of 
the neck. In Case I., there was once stiffness of the neck in an 
attack. 

This peculiar headache was distinctly paroxysmal, but not at 
all periodical or influenced by any apparent outward circum- 
stance. In both cases nausea accompanied the headaches, and 
in Case II. it is clearly stated that the nausea was secondary in 
point of time. 

Case I. was made relatively clearer by the previous history of 



OCCIPITAL HEADACHE IN UREMIA. 435 

convulsions, and by the fact (not stated in the notes, but quite 
clear in my recollection) that the surgeons in attendance then 
(in- 1876) found albumen in the urine. 

Case II. was greatly complicated by the presence of symptoms 
of slight paralysis, partial ptosis and a weak right leg. I am 
now disposed to think that these phenomena, together with the 
astonishing debility, staggering gait, and the sluggish state of 
the mind which I observed in this patient, were due to bromin- 
ism ; a condition to which I have called attention as a possible 
serious complication in the diagnosis of disease. 

I would also remark that the symptoms of renal disease were 
not marked ; in one case there was no oedema, in the other a 
mere trace ; neither patient had the dyspeptic symptoms or the 
frontal headache which often suggest renal disease, and neither 
patient has the " Brighty look " which is so well known. 

It is to be observed that the occipital sensation in these cases 
was true pain, not the painful paraesthesiae which are sometimes 
due to lithaemia and oxaluria, and sometimes to eye-strain, and 
which are erroneously (or rather insufficiently) designated as 
cerebral hyperemia. 

In some respects the story of these cases is imperfect, and I 
particularly regret the lack of observations upon the quantity of 
urine passed, and upon the state of the arterial tension. 

Still I am inclined to believe that the publication of these 
cases may serve to render more accurate the diagnosis of occipi- 
tal headache, and to illustrate the utility of critically examining 
the urine in cases of any degree of obscurity ; more especially 
as occipital headache is scarcely mentioned as a symptom of 
uraemia. 



THE LOCALIZATION OF DISEASES IN THE SPINAL 

COED.* 

I have designed this lecture as a pendant to Dr. Gray's dis- 
course upon the new anatomy of the spinal cord and its intra- 
cranial expansion. In the last fifteen years advances in the 
normal and pathological anatomy and the physiology of the 
nervous centres have progressed hand in hand, one illustrating 
and confirming the other. 

At the beginning of this century, and from that time until 
some fifteen years ago, though great progress was achieved in 
the clinical description of spinal diseases, from Ollivier to 
B-rown-Sequard ; and though we have acquired some knowl- 
edge of the pathological anatomy of the points involved, almost 




A 

Fig. 1. 
diageam of tbansyebse section of the spinal coed. 
A. Anterior median fissure, p. Posterior median septum. 1. Columns of Goll. 2. Columns of 
Burdach. 3. Direct cerebellar fasciculi. 4. Crossed pyramidal columns. 5. Lateral columns. 
6. Anterior columns. 7. Direct pyramidal columns. 8. Posterior gray horns. 9. Anterior 
gray horns. Stippled part— Gray matter. Shaded part— ./Esthesodic system. Unshaded 
part — Kinesodic system. 

* Delivered before the Anatomical and Surgical Society of Brooklyn, April 12th, 
1880. Reprinted from the Annals of the Anatomical and Surgical Society, 
Brooklyn, vol. ii., No. 12, 1880. 



LOCALIZED SPINAL LESIONS. 487 

no attempt had been make to localize the lesions of various 
diseases in definite sections of the spinal cord. The admirable 
spinal localization of the present day we owe to the accumulated 
labors of Cruveilhier, Tiirck, Charcot, Leyden and Erb. 

I shall offer you to-night a brief review, of this localization 
of diseases in the spinal cord, as founded upon normal anatomy, 
physiology and pathological anatomy. Such a study will be 
facilitated by admitting as practically correct a somewhat rough 
division of the spinal cord into two unequal regions, one includ- 
ing the posterior columns and the posterior gray matter, serving 
for the transmission of centripetal or sensory impulses, and the 
second, much larger, including the anterior gray horns, the 
anterior columns and the ant ero -lateral columns, serving for 
the transmission of motor centrifugal impulses. The former 
region is the aesthesodic system of the spinal cord, the latter the 
kinesodic system. The accompanying wood-cut illustrates the 
limits of these two systems, on a transverse section of the spinal 
cord. 

The following table embodies the principal localized lesions 
of the spinal cord which give rise to definite symptom groups, 
and which we are able to diagnosticate : 

LOCALIZED SPINAL DISEASES. 

A. Systematic diseases of the spinal cord : 

1. Diseases of the resthesodic system — 

a. Sclerosis of the posterior columns (progressive 

locomotor ataxia). 

b. Ascending degeneration. 

2. Diseases of the kinesodic system — 

a. Degeneration of anterior ganglion cells (progress- 

ive muscular atrophy). 

b. Inflammation of anterior gray horns (atrophic 

spinal paralysis of adults and children). 

c. Sclerosis of the lateral columns (tetanoid para- 

plegia). 

d. Descending degeneration, 

a. — of spinal origin ; 
p. — of cerebral origin. 



438 LOCALIZED SPINAL LESIONS. 

B. Focal affections of the spinal cord (injuries, tumors, foci 
of softening, myelitis transversa, clots, etc.) : 

a. In lumbar enlargement. 

b. In lower dorsal region. 

c. In upper dorsal region. 

d. In lower cervical enlargement. 

e. In upper cervical region. 
/. At the cauda equina. 

It will be impossible to do more this evening than to consider 
the first of the two great divisions — viz., that of systematic 
lesions. 

1. Diseases of the sesthesodic system. 

At the present time there is only one disease of this class 
— viz., posterior spinal sclerosis or progressive locomotor ataxia. 
The lesion consists, roughly speaking, in sclerosis of the pos- 
terior columns of the spinal cord. Since 1873 closer analysis at 
the hands of Charcot and Pierret has shown that the primary 
and essential sclerosis occupies only the external part of these 
columns — that which is adjacent to the posterior gray horns, 
and which histology teaches us is traversed by fibres of the 
posterior roots on their way to the gray matter of the cord. In 
most cases which come to the pcst-mortem table the median 
fasciculi of the posterior columns, or the columns of Goll, are 
likewise sclerosed, but this alteration is to be looked upon as 
secondary, as a form of ascending degeneration, and probably as 
wholly disconnected with the symptoms. Almost always scle- 
rosis of the external part of the posterior columns, or columns of 
Burdach, commences in the lumbar enlargement and advances 
upward. Ultimately, in old cases, the whole of the posterior 
columns as high as the medulla oblongata is sclerosed and de- 
generated, atrophied and hardened. Another part of the lesion 
of locomotor ataxia is a sclerosis and degenerative change in the 
posterior roots, extending to the ganglia on these roots and even 
involving them. In uncomplicated cases of locomotor ataxia, 
the anterior and antero-lateral columns, and the whole of the 
gray matter of the spinal cord, are healthy. The symptoms of 
the disease are chiefly of a sensory sort, and there is never any 
true paralysis in uncomplicated cases. The chief symptom in 
some respects, the initial symptom in the vast majority of cases, 
is a peculiar, almost pathognomonic neuralgia, which usually has 



LOCALIZED SPINAL LESIONS. 439 

its seat in the lower extremities alone, and sometimes affects the 
upper extremities and trunk, very rarely the head. The diag- 
nosis of locomotor ataxia depends so much upon this symptom 
and its exact appreciation that I need no other apology for stat- 
ing its characteristics with some fullness. 

a. The pains are vagrant ; they occur in innumerable spots in 
the affected parts, so much so that patients who have long had 
them are unable to enumerate the localities in which they have 
suffered ; or, rather, they can hardly name a region which has 
escaped. 

b. The pains do not occur in the course or distribution of 
recognized nerve trunks and filaments ; they are local pains, and 
this peculiarity may serve (with a) to distinguish between the 
pain of sclerosis and the true neuralgia (sciatica, etc.). 

c. The seat of the pain is commonly in an area of skin vary- 
ing in size from that of a pea to that of a small hand. In many 
cases pains are referred to the muscles, to the vicinity of the 
bones, and even to articulations and viscera. 

d. The pains are paroxysmal in a completely irregular man- 
ner ; they may occur every few moments for hours in one spot, 
or be altogether wanting for weeks ; or at times a single pain in 
a given region is the signal that the disease is not cured. It 
seems probable that the atmospheric disturbance (low barome- 
ter) which precedes a storm causes an increase in this symptom, 
or even calls it forth. 

e. The pains are sudden, and vary in severity from the sensa- 
tion caused by the penetration of a small knife-blade to that we « 
may imagine to result from tearing through the tissues with a 
hook or large knife ; or, the sensation is like an electric pain in 
suddenness. Perhaps most of the suffering in such cases is in 
the shape of stabbing pains in an ovoid or round area of skin 
(foot, thigh, arm, or shin) repeated every few seconds for hours, 
or even a whole day. The pain is often such as to make the 
strongest -willed man writhe and shriek. The seat of pain be- 
comes hyper algesic — i. e., painful to the lightest touch ; yet firm 
pressure may give relief. From their suddenness and electric 
character the pains of locomotor ataxia are often called fulgu- 
rating, or terebrating. 

The rationale or physiology of these characteristic pains is 
found in the morbid anatomy. As described above, there is in 
this disease a sclerosis of the connective tissue in the posterior 



440 LOCALIZED SPINAL LESION'S. 

columns of the spinal cord, and chiefly in their lateral portions — 
i. e., those portions which are traversed by fibres of the posterior 
roots. Irritation of these sensory nerve fibres is produced by 
the advancing sclerosis, and probably varies in degree according 
to changes in the circulation in the diseased spinal cord. 

It should be borne in mind that fulgurating pains usually pre- 
cede ataxia by three or four years ; but this neuralgic period 
may be shorter (a few weeks) or much longer, perhaps indefinite 
(in a case of my own, twenty-nine years). 

Other sensory symptoms of posterior spinal sclerosis are 
numbness and anaesthesia. The numbness often goes hand in 
hand with the pains, and is probably due to the same cause — 
viz., irritation of the posterior roots and their intra-spinal ex- 
pansion. It usually affects the feet first, and seems to ascend. 
When the upper extremities are involved, the numbness first 
shows itself in the finger tips. 

Anaesthesia is present in a large majority of cases ; probably in 
all which enter the second period — viz., the ataxic period. It 
may progress to such an extent as to make the patient perfectly 
unaware of any excitation applied to the legs (or hands) ; and to 
render him ignorant of the positions and existence of the limbs 
without the aid of sight or touch, the patient " loses his legs in 
bed." The anaesthesia is caused by the actual destruction or 
great compression of the sensory fibres already referred to. 

Destruction of the myeline and pressure on the axis cylinders 
by the sclerosed interfibrillar tissue may also explain a singular 
symptom — viz., the retardation of sensations — i. c, the occur- 
rence of a measurable time (10 to 120 seconds) between the 
pricking of a part and the acknowledgment of the pain by the 
patient. 

Other symptoms of sclerosis of the posterior columns are 
motor to all appearances, yet in reality depend upon interference 
of the disease with the spinal sensory apparatus. 

First. Diminished reflexes, pupillary, cutaneous, tendinous 
and visceral. For example, in many cases the pupils are small 
(may be unequal), and do not appreciably respond to light and 
shade, though they do change under accommodative efforts. 

Again, if we tap the ligamentum patellae in a patient suffering 
from fulgurating pains, or in one who has entered the ataxic 
stage, we observe that the quadriceps extensor femoris does not 
contract and cause a movement of the leg (the knee being semi- 



LOCALIZED SPINAL LESIONS. 441 

bent) as in health. This is known technically as absence of the 
patellar reflex, a new and most important symptom of posterior 
spinal sclerosis, one which in my experience hardly ever fails, 
and which deserves to be ranked as at least eqnal in importance 
with the fulgurating pains. Reflexes from cutaneous surfaces 
are also diminished or lost. The visceral reflex actions by 
which we micturate, defecate, and produce the sexual orgasm 
are likewise progressively impaired;- and thus we find these 
patients impotent as a rule, and presenting constipation and 
slow, imperfect micturition as symptoms. 

This reduction in reflexes is caused by disease of the intra- 
spinal sensory parts connected with the various organs and parts 
we test ; the arc for reflex actions is impaired in the posterior 
columns of the spinal cord or in corresponding regions of the 
spinal tract. 

The ataxic movement of the legs (and of the arms in some 
cases) which are characteristic of the second stage of the dis- 
ease, appears at a variable period after the beginning of the 
neuralgic stage (three months to ten years or more) and is 
essentially characterized by an irregular, asynergic action of the 
muscular groups which serve to produce a given movement. 
The legs are jerked forward and outward, and the heel brought 
forcibly down in the attempt to walk ; the fingers and arms 
oscillate and perform unnecessary excursions in trying to reach 
a given point, or accomplish a given action. Later, the irregu- 
larity of movement is so great that the patient is confined to bed. 

We are not yet agreed upon a theory of ataxia, but these 
hypotheses are deserving of consideration : 

a. That interference with sensory intra-spinal tracts diminishes 
the muscular tonus (chiefly produced in an unconscious reflex 
way), and that this atony varying in different muscles gives rise 
to the inharmonious movements. 

1). The anaesthesia affects the muscles as well as the super- 
ficial parts, and thus diminution or loss of the "muscular 
sense " is caused, and the patients can no longer guide their 
contractions. 

c. The sclerosis of the posterior columns affects other fibres 
beside common sensorv ones — viz., those arciform or lon<ntudi- 
nal commissural fibres described by Lockhart Clarke, and which 
seem to unite, for the purpose of harmonious action, the spinal 
centres for the various muscles of a group, or of a limb. If these 



442 LOCALIZED SPINAL LESION'S. 

commissural fibres be destroyed by sclerosis, we obtain ill- 
combined, asynergic muscular movements in the attempt to step. 

There are many other symptoms in the course of posterior 
spinal sclerosis, but those just analyzed are the characteristic 
ones — the ones which are logically related to the lesion. 

Under the head of diseases of the sesthesodic region we must 
also place the lesion of the posterior columns known as ascending 
degeneration. This lesion is limited to the posterior median 
columns, or columns of Goll, and diminishes in extent the higher 
we examine the spinal cord. We find this ascending degeneration 
above a spot in the spinal cord where it is compressed or de- 
stroyed, and it is also met with in progressive locomotor ataxia. 
Prof. Charcot and others teach that this extension of sclerosis 
from the columns of Burdach to the columns of Goll is a non- 
essential feature of locomotor ataxia, and is secondary. At any 
rate sclerosis or degeneration of the posterior median columns 
alone does not, as far as we know to-day, give rise to any special 
symptoms ; hence I can give you no clinical picture to accom- 
pany the pathological statement. We know only that the lesion 
exists in a living patient by learning the pathological state of 
the cord from other symptoms present. 

2. Diseases of the kinesodic system, including the anterior 
gray horns, the anterior columns, the antero-lateral columns, 
and the postero-lateral columns (or crossed pyramidal fasciculi). 

There are, as indicated in the table, several very definite and 
distinct affections of those parts. 

a. Degeneration of ganglion cells in the anterior horns. In 
this disease the protoplasm of these cells is very slowly trans- 
formed into granulo-fatty material, the cell processes are broken 
off, the nucleus and nucleolus destroyed, and in later stages 
there remains of the cell only a small mass of granules, or its 
place in the tissues may be vacant. These changes take place 
with extreme slowness, and the symptoms are correspondingly 
gradual in their appearance. For reasons which we do not un- 
derstand, this granular degeneration may be limited to a few 
groups of ganglionic cells, or may involve a large number of the 
cells from the medulla oblongata to the end of the cord. We 
are not acquainted with the lesion above the medulla, although 
there is no reason why the nuclei of the fifth, sixth, seventh, 
fourth and third cranial nerves should not suffer. I wish to lay 
particular stress upon the slowness of the degeneration, because 



LOCALIZED SPINAL LESIONS, 443 

of its harmony with symptoms and its contrast with allied 
states. 

Degeneration of anterior ganglion cells is externally expressed 
by muscular atrophy — usually progressive muscular atrophy. 
This singular disease shows itself often first in peripheral muscles, 
in hands and feet ; in other cases it attacks the shoulder, arm 
and thigh muscles. Indeed, it may commence in any muscu- 
lar group. Yet there are certain characteristic peculiarities in 
this wasting. 

1. It is very gradual ; fasciculi after fasciculi in the muscles 
undergo a diminution in size, lose their faradic contractility, and 
disappear, while adjacent fasciculi remain normal. There is no 
paralysis of a muscle, but a partial and gradual death of its con- 
stituents. 

2. The atrophy affects, in the vast majority of cases, symmet- 
rical and homologous parts. For example, both shoulders may 
be wasted, or the arms and thighs, or the forearms and legs- 
Unilateral muscular wasting is presumably not progressive mus- 
cular atrophy. 

3. The muscles which are undergoing the early changes of 
this wasting are the seat of what are called fibrillary contractions. 
These are produced by the involuntary rapid contraction of fas- 
ciculi of muscular fibres in a muscle. Sometimes a patient is 
covered with them. Some years ago these fibrillary* contractions 
were held to be pathognomonic, but I can assure you that this is 
not so, as they may be observed in lead palsy, in conditions of 
neurasthenia, in simple paralysis. Indeed, many years ago, 
Prof. Schiff, now of Geneva, showed that muscles separated 
from their motor nerves were prone to show fibrillary contrac- 
tions. 

The electrical reactions are diminished, but not altered in 
quality ; and the reduction or loss of reaction (to faradism) is in 
direct proportion to the wasting. In partly atrophied muscles 
some fasciculi look well and contract well, while their neighbors 
are thin, and rise but feebly under faradism. 

Uncomplicated degeneration of ganglion cells is unaccom- 
panied by numbness, anaesthesia, or vesical symptoms, though 
aching pains may be present in the affected limbs. 

b. Inflammation of the anterior gray horns ; myelitis anterior 
in adults and in children. 

Autopsies have shown that the lesion in this disease involves 



444 LOCALIZED SPINAL LESIONS. 

the anterior and central gray matter of the spinal cord, and that 
there may also be present, as secondary conditions, atrophy and 
degeneration of the antero-lateral columns (not distributed as in 
regular descending degeneration). The ganglion cells of the 
affected anterior horns are found in various states of change — 
swollen, containing vacuoles, filled with granulo-fatty matter, or 
shrunken and almost destroyed. Besides, the neuroglia round 
about these cells is always more or less altered. In some cases 
the Jesion might be designated as a diffused central myelitis 
with destruction of anterior ganglion cells. It need hardly be 
added that there exists an absolute anatomical relation between 
the level at which the changes occur in the spinal cord and the 
distribution of symptoms at the periphery. 

The symptoms of myelitis anterior are chiefly motor, very 
much as in group (a) ; but the morbid process being compara- 
tively or absolutely rapid, they appear in a strikingly acute or 
sub-acute form. 

First. Paralysis.. — In some few cases this appears with almost 
apoplectic rapidity (suggesting hemorrhage in the cord) ; in the 
majority the paralytic phenomena are complete in one or two 
days. Often we learn from the mother of a child who has 
myelitis anterior (infantile spinal paralysis) that she put the 
child to bed well, or simply a little feverish, and that the next 
morning both legs, or one extremity, or all the limbs were limp 
and paralyzed. In a minority of cases (adults) the muscular 
groups in the limbs lose power slowly, and a week or several 
weeks elapse before the patient is obliged to lie abed. It is 
important to contrast this paralytic loss of power, affecting a 
whole limb, or a whole muscular group, with the atrophy de- 
scribed under the head of " Progressive Muscular Atrophy." 

Second. Atrophy of muscles. — The palsied muscles in my- 
elitis anterior always undergo, in the course of the first four or 
five weeks, marked and even extreme atrophy. This wasting, 
even in the most sub-acute forms of myelitis anterior, is rapid 
as compared with the most rapid forms of progressive muscular 
atrophy. Besides, in the former disease, the atrophy, like the 
paralysis, always affects a whole muscle, or a muscular group, 
or the muscular apparatus of one or more limbs, en masse, and is 
not, as in the latter affection, fascicular in distribution. Fibril- 
lary contractions in wasting muscles are common in progressive 
muscular atrophy, and very rare in myelitis anterior. 



LOCALIZED SPINAL LESIONS. 445 

Third. Eemarkably distinct evidences of the degenerative 
reaction to electricity are obtained from the second to the tenth 
week. The nerve -trunks supplying the paralyzed muscular 
groups lose their excitability to faradism and galvanism, and 
these wasting muscles react only to galvanism, and that their 
reaction formula is altered from the normal : in general terms, 
we may say that An cc — Ka c c, or even An c c > Ka c c ; and 
all contractions are slow and wave-like. 

Fourth. The distribution of the paralysis is important for 
diagnosis and prognosis. In myelitis anterior the bladder and 
rectum are never paralyzed, and it is exceedingly rare to observe 
paralysis of the respiratory muscles, and of those which serve 
for deglutition. On the other hand, muscles supplied by the 
cranial nerves may be paralyzed. 

Fifth. An important symptom not usually referred to is aboli- 
tion of reflexes in the paralyzed parts, especially the tendon 
reflexes. • For example, if the muscles of the thigh (quadriceps 
extensor femoris) be paralyzed, no patellar tendon reflex can be 
obtained, just as in posterior spinal sclerosis. The mechanism 
is in both affections the same, but in either case different por- 
tions of the spinal arc serving for reflexes are injured ; in pos- 
terior spinal sclerosis the centripetal (sensory) portion of the 
arc is destroyed ; in myelitis the anterior (motor) portion. At 
an early stage of myelitis anterior, and in cases (infantile) where 
much fat serves to obscure fitrophy, this negative symptom 
acquires great value. 

Sixth. Sensory symptoms are very slightly developed in 
myelitis anterior. In some cases a degree of numbness or other 
paresthesia is experienced in the paralyzed limb for a few hours 
or days. In others severe neural pains are experienced. I style 
these neural because they apparently are in the course of nerve 
trunks or large branches, and are not in spots or patches like the 
fulgurating pains of posterior spinal sclerosis. Although the 
suffering in some few cases of myelitis anterior may be very 
severe, yet it is only careless observers who could mistake these 
pains for those of locomotor ataxia. Anesthesia is never present 
in myelitis anterior. When it is observed in any marked degree, 
the case should be designated as diffused central myelitis. 

Seventh. Fever is present in a majority of cases in children 
and adults. Other peculiar symptoms are vomiting, oedema of 
the extremities, hyperesthesia of affected parts, delirium. These 



446 LOCALIZED SPINAL LESIONS. 

rare symptoms occur in the first stage of the disease. In the 
atrophic stage the patient's general health is usually good. 

c. Sclerosis of the lateral columns has been recently described 
by Erb (1875) and Charcot (1876) as probably an independent 
or protopathic lesion of the spinal cord. To the sympiom-group 
characteristic of this lesion, Prof. Charcot has given the name 
of spasmodic tabes, Prof. Erb that of spastic spinal paralysis. 
I have proposed the name of tetanoid paralysis or paraplegia, 
which seems to me most expressive. 

The pathological anatomy of this affection is not as yet well 
established ; it is doubtful if the lateral columns generally are 
sclerosed, or whether the lesion is limited to their posterior 
portions, as in descending degeneration (vide infra). The lesion 
is always (?) bi-lateral. Another uncertain point is whether the 
lateral sclerosis is primary or secondary — i. e. f due to a focus of 
disease centrally placed above the beginning of the sclerosis. It 
seems to me that the weight of evidence is in favor of the 
latter view. 

The symptoms of tetanoid paraplegia consist in slowly in- 
creasing paresis in the legs (and arms rarely) with tendency to 
contracture and increase in all reflexes. The loss of power is 
exceedingly slow. The patellar tendon reflex is increased very 
early in the disease, and becomes greatly exaggerated. The skin 
of the feet forms the starting point of reflex muscular contractions 
when the patient is awake. Except at the close of the disease 
the affected limbs are relaxed in sleep. As a result of this 
increase of reflex action, there is a peculiar attitude and gait. 
The legs tend to cross one another, or actually do so from over- 
action of the adductors. The heel is drawn up, or at any rate 
raised, by over-action of the gastrocnemii and solei ; the legs in 
stepping are stiffened, their muscles sensibly hardened. The 
extremities are in a tetanoid condition. In later stages, in bed- 
ridden patients, the legs may be fixed in semi-flexion and 
adduction. These symptoms indicate clearly that the proper 
spinal activity — its reflex and automatic activity — is increased. 

Another motor disturbance, due to increased reflex action, is 
precipitate micturition and defecation. The patient must hurry, 
as from increased reflex action the bladder and rectum are apt 
to contract suddenly and involuntarily -upon their contents. We 
have here an example of incontinence through spasm — a con- 
dition to be carefully distinguished from paralytic incontinence. 



LOCALIZED SPINAL LESIONS. 447 

The muscles in parts affected with tetanoid paralysis retain their 
volume, nutrition, and normal electrical reactions. 

Sensory symptoms are practically wanting in this disease ; 
there is no anaesthesia, and seldom numbness. 

If there were time I should like to draw a contrasting picture 
between this condition and sclerosis of the posterior columns ; 
you can, however, easily do it for yourselves. 

In little children we not very rarely meet with the symptoms 
of tetanoid paralysis involving the legs alone, or all the limbs. 
The child cannot stand or walk because of the spasmodic con- 
dition of the legs and the apparent absence of cerebral stimulus; 
no anaesthesia is present. In some cases we find microcephaly 
and idiocy conjoined. Prof. Erb was the first to describe these 
infantile forms (1877), and he is disposed to think that patho- 
logical researches will show as lesions, sclerosis or want of 
proper development in the postero-lateral columns. I incline to 
the view that in these tetanized children the entire motor tract, 
from its cortical (cerebral) starting point to its distribution in 
the spinal cord, is more or less incompletely developed. The 
operation of circumcision is still gravely advocated as a cure for 
infantile tetanoid paralysis, but we have no recent and uncon- 
tradicted statements of cures ; besides, in my experience, Jewish 
children fully circumcised from birth frequently come to my 
clinic with these symptoms. 

A combination of b and c is recognized under the name of 
amyotrophic lateral sclerosis (Charcot). 

In this affection the lesions proper to b and c respectively are 
found in the spinal cord ; viz., destruction of the anterior ganglion 
cells, and sclerosis (degeneration probably) of the postero-lateral 
(or crossed pyramidal) columns. 

The symptoms correspond. We have a paralysis with atrophy 
in the upper and lower extremities, followed by contractions, 
with increased reflex in the non-atrophied and non-paralyzed 
muscles. 

d. Descending degeneration : a. Of spinal origin. This takes 
place when the physiological continuity of the spinal cord is 
interrupted. For example, after division of the cord with a 
knife, after great pressure from a tumor, or from a displaced 
vertebra, or from a focus of transversely localized myelitis, we 
observe these changes. They differ completely above and below 
the seat of pressure or of section. Above the lesion we find an 



448 LOCALIZED SPINAL LESIONS. 

alteration almost limited to the posterior median columns 
(columns of Goll) extending indefinitely upward toward the apex 
of the fourth ventricle. The degenerated tissue appears 
in transverse sections as a wedge-like area, with its base resting 
on the pia mater and its apex not quite reaching the posterior 
commissure (see Fig. 1). Careful examination often shows on 
each side of the cord another tract of altered nerve tissue — viz., 
a portion of the postero-lateral columns lying posteriorly to the 
crossed pyramidal column, and extending to the pia mater and 
the posterior gray horn — the ' so-called ascending cerebellar 
fasciculus (Flechsig). 

Below the lesion dividing the spinal cord the degenerations 
are found chiefly in two locations. First, in the crossed 
pyramidal columns (see Fig. 1) ; and, second, in the anterior 
columns, or, physiologically, the direct pyramidal columns. In 
these columns the descending degeneration extends to the lower- 
most portion of the cord. A more complete description of these 
columns will be given in the next section. 

The symptoms of the ascending degenerative changes, if there 
be any, are now unknown. As regards descending changes, 
they very probably are expressed by a more or less defined 
tetanoid state of the paralyzed limbs. In some cases this is 
well-marked, and constitutes the spinal epilepsy of Brown- 
Sequard, or may resemble the symptom group (c) attributed to 
the primary (?) lateral sclerosis. No sensory symptoms accom- 
panying either ascending or descending degeneration. 

p. Descending degeneration of cerebral origin. 

In this condition the foci of disease are found above the 
decussation of the anterior pyramids ; by far the greater number 
within the cerebral hemispheres. The nature of the lesion is, of 
course, immaterial, providing it be a destructive one. Such, for 
example, are clots in the motor region of the brain (more 
especially involving the anterior two-thirds of the internal 
capsule), patches of softening involving the motor convolutions 
or tumors in ' similar locations. Usually such a lesion is uni- 
lateral, but once in a while bi-lateral lesions exist, and we must 
be prepared for the existence of bi-lateral symptoms. 

From the focus of disease in these motor convolutions, or in 
the associated fasciculi of the corona radiata, the internal capsule 
(directly or indirectly involved), in general terms from the cen- 
tral part of the motor tract described to you by Dr. Gray, we 



LOCALIZED SPINAL LESIONS. 449 

can trace the degenerative changes with the naked eye (after six 
or eight weeks) to near the end of the spinal cord, through cer- 
tain well-known columns or fasciculi of the cerebro-spinal 
apparatus. Let us take an example : A patch of softening 
involving the motor convolutions bounding the fissure of Ro- 
lando in the right hemisphere, now known to be the source of 
direct innervation for the left upper and lower extremities. 
Beneath the patch there is an altered bundle of fibres of the 
corona radiata, extending downward in the anterior (or middle) 
portion of the internal capsule; thence into the right crus 
cerebri, the right inferior half of the pons, the right anterior 
pyramid of the medulla oblongata. At the base of the brain, 
in the crus, pons, and medulla, the degeneration is superficially 
evidenced by an atrophy of the parts and color. Below the 
medulla oblongata the changes are to a considerable degree 
invisible to the naked eye, but appear upon transverse sections 
of the spinal cord. On examining such sections we find changes 
in different localities in the two halves of the spinal cord. In 
the immense majority of subjects, the evident, the principal 
change, or secondary degeneration, is found in the left posterior 
lateral column, or, more strictly speaking, the crossed pyramidal 
column, so called because it is the continuation across the 
median line of the anterior pyramid which has (partially) de- 
cussated at the point known as the pyramidal decussation. The 
exact location of this bundle (in the transverse section) varies 
somewhat at different levels in the spinal cord. In the upper 
cervical region it lies deep in the lateral columns, and as we 
examine sections made lower down we find it more posteriorly 
and laterally. It is always in the posterior-lateral column, to 
use a rough anatomical term, and never quite reaches to the 
periphery of the cord; it diminishes in size (area) from above 
downward, and is quite lost to the naked eye in the lower lum- 
bar enlargement. In this crossed pyramidal column (see Fig. 1), 
I repeat, the principal descending degeneration is found. The 
other, smaller descending lesion, in our supposed case, is found 
in the right half of the spinal cord — i. e., on the same side as 
the original disease and the intra-cranial degeneration-paths. 
This second spinal degeneration involves the anterior column of 
the cord, strictly speaking — i. e., that fasciculus which lies be- 
tween the anterior median fissure and the anterior gray horn — 
the so-called column of Turck (see Fig. 1). This column em- 



450 LOCALIZED SPINAL LESIONS. 

braces those fibres of the anterior pyramid which have not 
crossed the median line ; hence the better name for this fascicu- 
lus is the direct pyramidal column. In our supposed case We 
find the right anterior column more or less altered throughout 
the length of the cord. 

To sum up : Below tho pyramidal decussation the secondary 
degeneration is found both in the crossed and the direct columns 
derived from one of the pyramids — tho right in our hypothetical 
case. 

A most important law, discovered and abundantly proved by 
Prof. Flechsig, of Leipzig, is that of variability in the 'pyramidal 
decussation. He found that in most of his specimens the cross- 
ing took place as above described, the great majority of pyra- 
midal fibres from the anterior pyramid crossing the median line 
and going to form the crossed pyramidal column, while a smaller 
number remained uncrossed and constituted the direct pyra- 
midal column. But in one of his foetuses this was reversed — 
i.e., the direct pyramidal column was much larger than tho 
crossed column. In several instances he found a degree of 
equality between the two columns derived from a pyramid. Ho 
concludes — and I entirely agree with him — that we must look 
upon the old law of decussation of motor fibres as liable to rare 
but remarkable variations. Ono result of such reversal of the 
law of decussation in a given individual would be to cause the 
paralysis from a cerebral lesion to appear on the same side of 
the median line. Although Brown-Sequard has written on the 
subject of paralysis from cerebral disease since the publication 
of Flechsig' s groat work (1876), he ignores these facts, which 
are alone sufficient to maintain the accepted hypothesis of cere- 
bral motor action, and also to completely refute his iconoclastic 
theories, since if we admit that sometimes the pyramidal dis- 
tribution is chiefly direct, we must deny the valuo of Brown- 
Sequard' s three hundred cases of paralysis on tho same side as 
the cerebral lesion. As long ago as January, 1878, I made use 
of this argument, which to my mind is convincing. 

To return to the subject of descending degeneration : 

Its symptoms consist in increased reflexes (from tendons espe- 
cially) and contracture, in the wholly or partially paralyzed 
parts ; arm and leg — rarely the face. It is useless to further 
describe this condition which we all see so often in uncured 
cases of hemiplegia. I would, however, call your attention to 



LOCALIZED SPINAL LESIONS. 451 

one important fact which I believe I was the first to notice and 
draw a conclusion from — viz., that during sleep in a warm bed 
the affected limbs are wholly or partially relaxed, and contract 
at once upon waking or upon exposure to the cooler air. I need 
hardly add that the contracture, like the paralysis in hemiple- 
gia, is greatest in peripheral parts. 

The classic theory of the physiology of contracture in hemi- 
plegia is that it is due to the secondary degeneration — i. e., 
actively caused by the lesion of the postero-lateral column. 
Seven years ago (see Archives of Scientific and Practical Medi- 
cine, Vol. I., p. 106, 1873) I rejected this hypothesis, and sug- 
gested a different one, which I have since elaborated and taught 
in my clinical lectures at the College of Physicians and Surgeons, 
New York. This hypothesis, which I intend shortly to publish 
in detail, is briefly that the spasm is due, not to direct irritation 
from the sclerosed (?) tissue in the postero-lateral column, but 
to the cutting off of the cerebral influence by the primary lesion, 
and the consequent preponderance of the proper or automatic 
spinal action — an action which is mainly reflex. This theory 
explains the phenomena observed in cases of primary spinal dis- 
eases with descending degeneration (a) and can be reconciled 
with results of experiments on animals (increased reflex power 
of spinal cord after a section high up, Brown-Sequard ; inhib- 
itory power of encephalon on spinal cord, Setschenow). 

Want of time will prevent us from considering the focal affec- 
tions of the spinal cord, classed in the table under section B. 



A CASE OF ABSCESS OE THE LEFT FEONTAL LOBE 
OF THE CEEEBEUM, WITH SPECIAL EEFEEENCE 
TO LOCALIZATION.* 

Ox April 11, 1880, I was asked by Dr. J. Lewis Smith to see a case in con- 
sultation with himself and Dr. J. R. Learning. The patient was a young 
married woman, aged about 28 years, who had formerly enjoyed good health 
and had borne several children. During the month of February one of these 
children had died after a severe illness, and she had undergone considerable 
fatigue. She seemed depressed, weak, and anaemic afterward. 

About four weeks before the date of the consultation she convplaincd of pain 
over the left eye. This was soon accompanied by swelling and exophthalmus, 
and on March 24th Dr. Knapp was called in and diagnosticated orbital (sub- 
periosteal) abscess. This was opened on March 26th by Dr. Knapp. 

It was remarked that the pus was under great tension, and that it spurted 
out a considerable distance when released. Pain ceased at once, the exoph- 
thalmus disappeared, and the wound quickly healed. Duriug the first few 
days of April all seemed going on well; the wound was healed; the patient 
was free from pain ; she was taking tonics, and on the 3d made a call on a 
near neighbor. 

• During the night of April 3d and 4th. one week before my examination, 
she awoke with severe headache and vomiting; ever since she has lain abed, 
presenting the following symptoms: headache, chiefly mastoid and through 
the base of the skull; occasional vomiting; irregular respiration; irregular 
and very slow pulse, varying from 60 to 50 beats per minute ; stupor and gen- 
eral feebleness. As negative points there were no symptoms about the eyes, 
objective or subjective, except a partial ptosis of the left upper lid (which 
had been incised); no fever, chills, convulsions, paralysis, aphasia; at no time 
had there been coma. The urine was free from albumen. 

Examination. — Patient was soporose, but could be aroused by loud speaking; 
she answered questions as if half asleep, but in such a way as to leave no 
doubt as to the preservation of language. She jmt up both hands to the 
mastoid regions when indicating the seat of pain. A minute inspection 
showed no paralysis except about the left eye, whose upper lid drooped and 
whose internal rectus was inert. The pupil on the left side was not fully di- 
lated, but it was a little wider than the right. The optic nerves appeared 
somewhat congested, and were dim at their periphery, but there was no 
actual choking. Patient appeared to feel pinching well everywhere. The 
thermometer showed no fever. The pulse varied from 53 to 66 beats per 
minute, and it was a reluctant, delusively full pulse, witli no real strength. 
The breathing was easy and regular, but friends of the patient described quite 

* Reprinted from the Archives of Medicine, vol. v., No. 1, February, 1881. 



A CASE OF CEREBRAL ABSCESS. 



453 



well a Cheyne-Stokes breathing which they had observed. There was neither 
redness nor tenderness about the site of the orbital abscess. 

I diagnosticated an abscess of the brain, probably in the left frontal lobe, 




PIGt l.— Apparent location of the abscess, drawn on an Ecker's diagram of the brain. 

and expressed the opinion that the patient was in imminent danger. She died 
the next day in a comatose state, no new symptom having been observed. 

It was then learned that for two years Mrs. F. had suffered from frequent 
attacks of headache, lasting several hours. The pain was frontal, and some- 
times extended along the nose and into the left temple. There had never 
been symptoms of chronic nasal catarrh. 



The autopsy was made on April 13th, about thirty hours post- 
mortem, in the presence of Drs. H. Knapp, J. R. Learning, J. 
Lewis Smith (the attending physician) and Richard Wiener. 
"We found a large abscess, the size of an English walnut, in the 
left frontal lobe. It seemed to lie wholly under the cortex 
cerebri, in the convolutions of the orbital lobule and in the sec- 
ond frontal convolution. Yiewing the hemisphere from the side, 
the apparent posterior limit of the abscess was the anterior 
border of the lower part of the third frontal gyrus. Fig. 1 
indicates the seat of the soft, fluctuating, bulging abscess. Its 
depth and penetration were not then determined, as it was 
thought best to harden the brain as a whole before making 
sections. 

The external connections and origin of the abscess were most 
interesting. There was only one point of adherence between the 
diseased frontal lobe and the dura mater, and that was over the 



454: A CASE OF CEBEBBAL ABSCESS. 

orbital plate of the frontal bone immediately under the swollen 
frontal lobe. There the dura mater was thickened and adherent 
to the pia mater and cortex cerebri, forming the inferior wall of 
the abscess, over a space as large as a ten-cent piece (about 15 
mm.). Under this patch of pachymeningitis the orbital plate 
of the frontal bone was necrosed and perforated ; a probe was 
easily passed into the orbit. 

In the orbit, under its periosteum, pus was found, and parts 
of the roof and the inner wall of the orbit were carious. Careful 
dissection by Dr. H. Knapp showed disease of a similar kind in 
the ethmoidal cells and frontal sinus. I need say nothing more 
of the condition of these parts and of the pathology of the orbital 
abscess, as the case has been fully reported from this point of 
view by Dr. Knapp.* 

The appearance of the necrosed orbital plate and of the thick- 
ened, adherent dura mater was precisely similar to what I have 
several times seen in cases of suppurative disease of the internal 
ear with cerebral abscess by contiguity. The genesis of the 
abscess must have been alike in the two situations. 

In December, the brain having been sufficiently hardened in 
bichromate of potash solution, I imbedded it in Gudden's micro- 
tome, and made several horizontal sections through the whole 
brain with the view of demonstrating the relations of the abscess. 
These cuts showed that the abscess was of quite as large a size 
as at first supposed, almost perfectly globular in shape, measur- 
ing about 38 mm. in diameter. It contained ordinary pus, and 
was lined by a distinct membrane 1-2 mm. thick. The anterior, 
inferior and external limits of the abscess were thinned cortex 
and pia mater; superiorly, posteriorly, and internally, it was 
bounded by apparently normal white substance. The whole of 
the white centre of the frontal lobe, except a portion near the 
convexity of the hemisphere, was destroyed to within 10 mm. 
of the folds of the island of Eeil, and about 8 mm. of the head 
of the nucleus caudatus. The mass of white substance connect- 
ing the inferior and posterior part of the third frontal convolution 
and the anterior gyri of the island of Eeil with the internal 
capsule, was uninjured. 

This last fact is of capital importance in estimating the bear- 
ing of this case upon the current notions of cerebral localization. 

* Archives of Ophthalmology, vol. ix., p. 185, 1880. 



A CASE OF CEREBRAL ABSCESS. 455 

The above description of the topography of the lesion, es- 
pecially its posterior limitation, is made from the surface exposed 
by the lowest cut made, viz., one passing through the speech- 
centre of Broca, about 10 mm. above the apparent commence- 
ment of the fissure of Sylvius (pia still adherent). Fig. 2 is 
faithfully drawn from a photograph taken of this section-surface. 
The rest of the brain was healthy to the naked eye. 



Fig. 2.— Kelations of the abscess as shown in a horizontal section of the brain made at the level of 
Broca's speech-centre. Drawn from a photograph of the specimen. Occipital lobe cut off. 

This remarkable case seems to me of much importance as a 
negative contribution to cerebral localization. It is in exact 
accord with recent experimental data, and with the post-mortem 
finding of the last ten years, that an abscess placed like this one 
should give rise to no motor symptoms, and should not cause 
aphasia. It is wholly within what are now called the inexcitable 
districts of the brain. The only symptoms present were the 
partial paralysis of the left third nerve (more immediately 
caused by the orbital abscess?) and signs of intracranial 
pressure. Yet it is important to note that in spite of the enor- 
mous pressure which must have existed there was no actual 
neuro-retinitis. 

I have elsewhere reported another case of (smaller) abscess 
in precisely the same location (left frontal lobe) in which no 
symptoms referable to this lesion were present.* 

* A contribution to the study of localized cerebral lesions. Transactions of the 
American Neurological Association, vol. ii., pp. 122-4, N. Y., 1877. 



456 A CASE OF CEREBRAL ABSCESS.' 

On the other hand numerous autopsies are on record in which 
a smaller lesion (softening, hemorrhage, etc.), placed a centi- 
metre farther back in the left frontal lobe, involving the posterior 
part of the third frontal gyrus or the band of white substance 
between it and the nucleus caudatus, has given rise to severe 
symptoms, hemiplegia or aphasia, singly or combined. 

In the paper just quoted I have described such cases. 



ON THE EAELY DIAGNOSIS OF SOME OEGANIC DIS- 
EASES' OF THE NEBYOUS SYSTEM.* 

Peobably no one would deny the desirability and utility of 
making an accurate diagnosis of disease at the earliest possible 
period, and one of the results of recent progress in the medical 
art is increased possibility in this direction. "We can recognize 
diseases which, though existing, were unknown to practitioners 
of thirty or fifty years ago, and we can also determine the exist- 
ence of some of these affections at a much earlier period of their 
evolution than we could ten or even five years ago. The sciences 
of semeiology and of diagnosis have unquestionably progressed 
greatly in the last generation, and this is more especially shown 
in the history of specialties, as ophthalmology, dermatology, 
gynecology, and neurology. I may be permitted to say that it 
is a duty and privilege of the specialist" to inform the profession 
at large of the advances made in his department in diagnosis 
and therapeutics, in order to enable the general practitioner to 
apply the new knowledge, or the confirmed old knowledge, to 
the advantage of his patients. 

It is with such a motive that I would call your attention to 
the possibility and desirability of an early diagnosis of two or 
three organic diseases of the nervous system. Probably I shall 
name no new symptoms, but will aim to call your attention to 
the really valuable symptoms of these affections, and to the 
significant grouping of these symptoms. 

I have selected three affections which are now quite well 
known to us, and yet which, judging from my experience, are 
frequently ignored during long periods of their formative 
stages : I refer to posterior spinal sclerosis (progressive loco- 
motor ataxia), dementia paralytica, and cerebral tumor. 

I. Posterior spinal sclerosis, or progressive locomotor ataxia. 

While willing to admit the occasional occurrence of abnormal 
cases of this disease, in which ataxia appears with little pre- 
monition, yet I claim that the general practitioner at the pres- 

* Reprinted from the Medical Record, Feb. 26, 1881 



458 THE EARLY DIAGNOSIS OF ORGANIC DISEASE. 

ent day should diagnosticate the disease in the clearly defined 
first stage, or pre-ataxic period, which may last from a few 
months to several years. The vast majority of cases exhibit 
this first stage, and its symptoms are peculiarly characteristic, 
if not pathognomonic. In general terms the symptoms of this first 
stage consist in peculiar pains, and in reduction or abolition of 
reflex movements in different parts of the body, and from a com- 
bination of these a diagnosis of great probability of accuracy can 
be made years before the patient's gait becomes disordered. 

If we assume that nineteen out of twenty victims of posterior 
spinal sclerosis pass through this neuralgic or pre-ataxic stage, 
we will not be far out of the way. 

The pains of posterior spinal sclerosis are almost pathogno- 
monic, especially when described by an intelligent educated 
patient. They have the following characters : 

a. The pains are vagrant ; they occur in innumerable spots in 
the affected parts — so much so that patients who have long had 
them are unable to fully enumerate the localities in which they 
have suffered ; or, rather, they can hardly name a region which 
has escaped. 

b. The pains do not, as a rule, occur in the course or distri- 
bution of recognized nerve-trunks or branches ; they are local 
pains, and this peculiarity may serve (with a) to distinguish 
between the pains of sclerosis and those of true neuralgia 
(sciatica, etc.). 

c. The seat of pain is commonly in an area of skin varying in 
size from that of a pea to that of a small hand. In many cases 
pains are also referred to the muscles, to the vicinity of bones, 
and even to articulations and viscera. 

d. The pains are paroxysmal in a completely irregular man- 
ner ; they may occur every few moments for hours in one spot, 
or may be altogether wanting for weeks ; or at times a single 
pain is the signal that the disease is not cured. It seems prob- 
able that the atmospheric disturbance which precedes a storm 
(areas of low barometer) causes an increase in this symptom, or 
even calls it forth. 

e. The pains are sudden, and vary in severity from the sensa- 
tion caused by the penetration of a small knife-blade to what we 
may imagine to result from tearing through the tissues with a 
hook or large knife ; or the sensation is like a painful electric 
shock. Perhaps most of the pain in such cases is in the shape 



THE EARLY DIAGNOSIS OF ORGANIC DISEASE. 459 

of stabbing pains in an ovoid or round area of the skin (foot, 
thigh, arm, shin, etc.), repeated every few seconds for hours or 
even a day or two. The suffering is often such as to make the 
strongest-willed man writhe and shriek. The description of the 
pains, t. <?., their comparison with known sensations or physical 
conditions, varies greatly, according to the fertility of the pa- 
tient's imagination and his command of language. From their 
suddenness and electric character the pains of posterior sclero- 
sis are often called fulgurating or terebrating. The seat of pain 
usually is hyperalgesic, L e., painful to the lightest touch during 
the paroxysm ; yet firm pressure sometimes gives relief. 

Second. — Diminution of various reflexes throughout the body. 

This is best observed in the iris and at the patellar tendon, 
though the constipation and imperfect micturition which are 
such frequent symptoms of the disease are phenomena of the 
same order. 

a. The impairment of iritic reflex action (" pupillary reflex ") 
was first intelligently studied in 1869 by Dr. Argyll Kobertson, 
of Edinburgh. His observations have since been abundantly 
verified by numerous observers, and an exhaustive paper on the 
subject has been published by Prof. "W. Erb, of Leipzig, in the 
Archives of Medicine, October, 1880. Kobertson and others after 
him noticed that the pupil of tabetic patients did not dilate in 
the shadow and contract in the light, as do normal pupils ; and 
they further observed that during the effort of accommodation 
there occurred a normal pupillary contraction. In other words, 
the reflex iris movements were abolished, while its associated 
quasi-voluntary movements were preserved. These phenomena 
I have observed in almost all my patients suffering from poste- 
rior spinal sclerosis, and I am in the habit of calling the atten- 
tion of students to the symptom. In two of the patients now 
under my care this condition is not present, but these have been 
cases of abnormal sclerosis, in which all the symptoms appeared 
in a most irregular manner. • 

The pupils in a suspected case of posterior spinal sclerosis 
are to be tested in the following manner : the patient is jDlaced, 
seated or standing, facing a brightly illuminated window, and told 
to keep his look fixed on some distant object, such as a house or 
tree. By alternately closing and opening the lids, or better, by 
shading the eyes with one's hand momentarily, it is easy to see 
if the pupils change diameter. It is of the utmost importance 



460 THE EARLY DIAGNOSIS OF ORGANIC DISEASE. 

that the patient's intelligent assistance be secured, in order that 
his gaze shall remain adjusted for distance. In a given case the 
absence of reaction to light having been noted, we next hold up 
one finger or a small object within a foot of the patient's face 
and bid him look at it. At once the pupils contract, and do so 
in proportion to the accommodative effort and the coincident 
convergence ; when the patient looks at the distant object, and 
relatively or absolutely relaxes his accommodation, the pupils 
dilate again. 

The finding of such a condition of the pupil — the existence of 
Robertson pupils, if you will allow the expression — is now con- 
sidered of nearly as much importance for diagnosis as the occur- 
rence of fulgurating pains. 

b. Diminution and abolition of reflex action in the peripheral 
apparatuses is best studied at the knee. 

We test the so-called patellar reflex, or knee reflex, or patellar 
tendon reflex in the following Ways : the patient being seated, is 
told to cross one leg over the other in a natural manner, and to 
let the muscles relax ; or seated, we place our left hand under 
the popliteal space, tell the patient not to help us, to let the leg 
hang loose, or, in popular parlance, " dead," and lift the whole 
limb so that the foot swings a couple of inches above the floor ; 
then we tap the skin over the whole of the region from the inser- 
tion of the quadriceps femoris to the tuberosity of the tibia, 
with one or two finger-tips applied as in percussion. The place 
whence a reflex quadriceps contraction is most apt to occur is 
about midway between the lower end of the patella and the 
tibial protuberance. The taps should be gentle at first, and if 
these fail, harder ones are to be tried. A third mode of proced- 
ure, which is very good indeed, is to seat the patient on a table 
so that his legs dangle some two or three inches beyond its 
edge ; then we tap the patellar region as above described, with- 
out supporting the thigh with our left hand. The test may be 
well done through the patient's clothing, yet it is desirable, 
especially in doubtful cases, to tap the bare skin. Another im- 
portant precaution is to secure the absolute relaxation of the 
patient's muscles, and to divert his attention from what you are 
doing. Even with all precautions it is sometimes next to impos- 
sible to secure this indispensable muscular relaxation. In the 
healthy subject this test develops a contraction of the quadriceps 
extensor femoris and causes an extension of the leg, or a sudden 



THE EARLY DIAGNOSIS OF ORGANIC DISEASE. 461 

jerk. In a very early stage of posterior spinal sclerosis no con- 
traction takes place. 

I would also call attention to the occasional occurrence of 
reflex movements of the thigh produced by contraction of the 
iliac group of muscles during the knee test. I have an example 
of this distant reflex action in a typical case of sclerosis of the 
posterior columns, in which the quadriceps does not contract 
at all. 

"While claiming very great diagnostic value for this negative 
symptom, I would not be understood as attaching pathogno- 
monic significance to it, as we all know that there are a few 
seemingly healthy individuals in whom the patellar tendon 
reflex is lacking, and also that there are other diseases which 
diminish or abob'sh it. Indeed, I may say that I recognize no 
pathognomonic symptom, and even in attempts to push diagnosis 
to an extreme delicacy, would urge that reliance be placed on 
the grouping of symptoms, rather than on any one of the signs, 
however constant and important it may appear. 

Physiologically analogous to this condition of lo§s of tendinous 
reflexes is the flabby state of the muscles in the affected parts. 
This is not due to any positive atrophy, as electrical tests show 
no marked departure from the normal reactions ; but to impair- 
ment of what physiologists call muscular tonus, a state of partial 
contraction or tension of muscles which is kept up by the inevit- 
able and continued excitation of the cutaneous nerves by air, 
clothing, surrounding objects, etc., acting in a reflex way through 
the spinal cord. It has been recently claimed that this loss of 
muscular tonus was the most important factor in the production 
of the ataxic movements which characterize the second stage of 
the disease. 

The vesical and rectal reflexes are diminished in posterior 
spinal sclerosis. Slow, irregular micturition is complained of 
by most patients, in the first stage and in the second. We usu- 
ually micturate without using much volition, but the tabetic 
patient is obliged to strain and to try hard to pass water. 
Defecation is, like micturition, a semi-voluntary act, and in the 
late first stage of the disease in question, constipation becomes 
more and more marked, and that through loss of the automatic 
or reflex action of the rectum and adjacent muscles. 

The sexual act is, in my experience, frequently impaired and 
sometimes almost lost before the second stage sets in. The acts 



462 THE EARLY DIAGNOSIS OF ORGANIC DISEASE. 

of erection and emission are usually brought about in a reflex 
manner by irritation of the skin and mucous membrane of the 
genitals. As a result of diminished spinal reflex action we have 
imperfect erections, and either premature emission, or, what is 
more common, I believe, very slow production of the orgasm, 
and impossibility of repetition within a reasonable time. • 

Some writers admit abnormally great sexual power in the early 
stage of tabes, but I am not sure to have met with more than 
one or two cases in which this seemed to be the case. In one 
of the patients, a female, I became convinced that her extraor- 
dinary capacity for sexual intercourse was not in a strict sense 
pathological or pre-tabetic, but had been marked in one shape 
or another from childhood. 

It seems reasonable at the present time to advance this gen- 
eral proposition : that in posterior spinal sclerosis the various 
reflex actions performed by means of those portions of the cord 
which are the seat of sclerosis, are diminished or lost ; or, to 
put it in another way more useful for practice, it may be said 
that the limitations of loss of reflex action in different parts of 
the body accurately indicate the limits of sclerosis in the pos- 
terior sensory apparatus in the spinal axis. 

Third. — The occurrence of paralysis of ocular muscles. 

A very large proportion of tabetic patients tell of past or 
present diplopia, and in a certain number of cases the ocular 
paralysis precedes the pains and ataxia by several years. So 
true is this statement, that it has become an established practice 
with neurologists and ophthalmologists to suspect posterior 
spinal sclerosis in adults who present themselves with strabis- 
mus, diplopia, or ptosis. In such a case we should carefully 
question the patient about the occurrence of fulgurating pains, 
and test the pupillary and tendinous reflexes. I need hardly add 
that another obligatory line of inquiry in such cases is with 
reference to symptoms of syphilis. 

The same remarks apply to atrophy of the optic nerve, which 
is occasionally an early symptom. 

• I have not the time to refer to the gastric, laryngeal and rectal 
crises and the peculiar forms of arthritis which once in a while 
occur early in the disease. 

It seems to me that, by a critical appreciation of the above 
symptoms in a patient, the diagnosis of the first, or neuralgic 
stage, of posterior spinal sclerosis is as certain as the diagnosis 



THE EARLY DIAGNOSIS OF ORGANIC DISEASE. 463 

of any internal disease, not excepting such affections as pneu- 
monia or valvular cardiac disease. Several autopsies are now on 
record, made during this first stage, and in these, sections of the 
cord showed sclerosis of the posterior columns. I have one 
such observation of my own : fulgurating pains for about thirty 
years, absence of patellar reflex while under observation (two 
years), dilatation of one pupil, no trace of ataxia. The sclerosis 
of the posterior columns in this patient's spinal cord is visible 
to the naked eye. 

It is often objected that the pains of ataxia are not absolutely 
reliable for diagnosis. This may bo true when the patient is 
stupid, or when the physician is not careful to ascertain the 
precise character of the pains. 

The only two conditions in which pains somewhat resembling 
fulgurating pains occur, in my experience, are paralytic dementia 
and gout. In the former disease, slight fulgurating pains — 
" smaller " pains, if I may be allowed the expression— are de- 
scribed by the patients ; but in many of these cases autopsy 
shows that, besides the cerebral lesions proper to the disease, 
the posterior columns of the cord exhibit pathological alter- 
ations ; so that these cases are, after all, quas /-tabetic. The 
sharp pains of gout are short, stabbing pains in the skin of 
various parts of the body, compared by the patients to the prick 
of a needle, cold or hot. There is no tendency to repetition of 
the pain in one spot for hours or days ; the sensations appear in 
various parts of the body, and are bearable. It is but right to 
add that this statement is based on very few observations, and 
requires verification. 

The differential diagnosis of fulgurating pains from the pains 
of neuralgia, strictly speaking, is very easy. In neuralgia the 
pain is in the course and distribution of one or two (seldom) 
nerve trunks and their branches ; it may be paroxysmal, but 
does not assume the excessive irregularity of the tabetic pains — 
agony for a few hours, and freedom from pains for hours, days, 
or weeks. The hyperesthesia, in fulgurating pains, is at the 
seat of pain. In neuralgia we find regular " tender points " 
along the nerve trunk, or where its branches become superficial. 
The lightest touch causes pain in the painful districts in tabes, 
while the tenderness of nerves in neuralgia is usually demon- 
strable only by firm, localized pressure. Further, true neuralgia 
is seldom bilateral, while it is the rule for fulgurating pains to 



464 THE EARLY DIAGNOSIS OF ORGANIC DISEASE. 

appear on both sides of the median line — in both lower extrem- 
ities, for example. A last important distinction is that neuralgia 
is relievable or curable, whereas fulgurating pains are practi- 
cally incurable, and are fully relieved only by morphia injections. 

The confusion so often made between " rheumatism " and the 
first stage of sclerosis is even less pardonable. Of course no 
practitioner would mistake fulgurating pains for articular rheu- 
matism ; the error is with respect to " rheumatism," so-called, 
affecting muscular masses, and aponeuroses. In these affec- 
tions the pains are usually dull, nearly constant, and dis- 
tinctly aggravated by movements. Pressure must be firmly 
made upon the parts to produce pain, whereas in fulgurating 
pains the condition is one of cutaneous hyperalgesia under a 
slight touch. Again, this "rheumatic" condition is distinctly 
amenable to treatment (counter-irritants, etc.), whereas the pains 
of posterior spinal sclerosis are, in one sense, incurable. 

II. The second disease of the nervous system to which I would 
direct your attention as the object of more exact and earlier 
diagnosis^ is 'paralytic dementia. By this term is meant the pas- 
sive form of an affection which consists in peri-encephalitis, 
adhesion of the meninges, and various secondary, degenerative 
changes in the brain and in the posterior columns of the spinal 
cord. Chronic peri-encephalitis also presents itself in an active 
or delirious form, which is known as general paralysis or pare- 
sis. In neither form is there a positive condition of paralysis at 
any time, except as a complication from the occurrence of cerebral 
hemorrhage or softening. Both the semeiological names, para- 
lytic dementia and general paresis, are, strictly speaking, mis- 
nomers ; yet we accept them as sufficient. 

The semeiology of peri-encephalitis is complicated, and it 
would be beyond the scope of this essay to describe it in detail. 
I merely wish to call your attention to the symptoms which, in 
my opinion, are earliest in their appearance and significant of an 
incurable disease. These are tremors or fibrillary contractions 
in various muscular groups, especially in the tongue, facial, and 
brachial muscles ; a tremulous, thick, and vibratory speech ; in- 
equality of the pupils ; dementia. 

The tremor of paralytic dementia probably first makes its 
appearance in the facial and lingual muscles. It consists in non- 
rhythmical contractions of small muscles or of fasciculi of muscles, 
which are either present in the quiescent state of the features, 



THE EARLY DIAGNOSIS OF ORGANIC DISEASE. 465 

or are excited by emotion or by the performance of a voluntary 
movement, as showing the tongue or the teeth. Sometimes in- 
numerable fine, fibrillary tremors cover the face, while in some 
cases the movements are coarser and irregular enough to merit 
the term choreic. The tongue exhibits both sets of tremors — 
the very fine, fibrillary ones and the large, choreic oscillations. 
There is also, though usually at a later stage, some shrivelling 
or atrophy of the tongue. 

The hands are tremulous, usually in a fine semi-rhythmical 
way. This trembling is sometimes scarcely visible, but is per- 
ceptible as a delicate parchment-like fremitus on holding up the 
patient's extended fingers between ours. In the lower extrem- 
ities the tremulousness is not apparent. 

The speech is affected as a result of this tremor and as the 
result of a certain want of co-ordination in the muscles of articu- 
lation. Words are quickly spoken, with some syllables omitted 
or blurred, or with a terminal syllable left off. The articulate 
sounds which are produced are heard as vibratory or tremulous, 
and the speech seems thick. Patients semi-unconsciously avoid 
long or difficult words in conversation, and even seek round- 
about ways of expressing their meaning by shorter words. Be- 
sides this vibratory tremulousness in articulation there is an 
imperfection in the pronunciation of words, long words espe- 
cially. Kemedy is pronounced "remdy"; constitution, " con- 
stution " ; infallibility, " infalliby." The last syllable may be 
badly sounded, or even omitted. I have known this characteris- 
tic speech to be the only well-marked symptom, and to be fol- 
lowed by dementia, exaltation, etc. Occasionally a patient comes 
to us complaining of this defective articulation. I now recall 
two such cases, one of which died three years later in a Ger- 
man private asylum, with all the symptoms of general paralysis. 

Just as spoken language is affected by the facial and lingual 
tremor, so is the handwriting altered by fibrillary contractions 
in the muscles which govern the movements of the fingers. 
A tremulous, jagged, wholly irregular handwriting results, and 
in some cases, where dementia is present, words or syllables are 
frequently omitted in composition. 

The pupils, in paralytic dementia, are either very small or 
irregular, usually the latter. The reaction of the iris to the 
influence of light may be diminished or abolished. 

I may here say, by way of parenthesis, that small and unequal 
80 



4:66 THE EARLY DIAGNOSIS OF ORGANIC DISEASE. 

pupils in a person of middle age, from twenty-five to sixty, 
should lead to an inquiry into the possible existence of one of 
three morbid states, viz. : paralytic dementia (or general paraly- 
sis), sclerosis of the posterior columns, cardiac or aortic disease 
(intrathoracic disease). 

In my experience, the patellar tendon-reflex is often increased 
in paralytic dementia. 

The dementia, or failure of mental power, is sometimes im- 
possible to detect until after the more peripheral physical 
symptoms have existed for some time. It is possible for the 
psychical symptoms to precede the physical ; sometimes the two 
appear to develop simultaneously ; usually, I believe, the physical 
symptoms already studied are apparent for months before the 
mind shows decay. 

Dementia is evidenced by impairment of memory for recent 
events, by loss of the power of comparison, and consequently of 
judgment. Many of the automatic or quasi-automatic acts of 
cvery-day life which form a part of the patient's manner and 
individuality are badly performed or omitted. This leads to 
w hat is known as change of character in the subject ; he becomes 
less neat in his attire or personal cleanliness ; he loses his table- 
manners, handling his spoon, fork and knife awkwardly, soiling 
his clothing with drippings of food, etc. The impairment of 
judgment is probably one of the factors in the immorality and 
tendency to alcoholic indulgence which are so frequent in this 
disease. 

Yet, in the midst of this increasing moral wreck, so visible to 
the immediate relatives of the patient, there may remain a degree 
of correctness in thought and success in every-day occupation 
which may impose upon strangers, and even upon a judge and 
jury. The things which the patient is in the habit of doing 
every day, and about which he has thought many years, such as 
professional work and business transactions, may be fairly well 
executed, while the tremors, pupillary irregularity, impaired 
articulation and handwriting, together with alteration of moral 
character, make the medical observer recognize a fatal pro- 
gressive disease of the brain. These cases come more frequently 
under the observation of general practitioners than under that 
of the specialist, whether asylum physician or neurologist. 
They are very frequent in our midst, and their early recogni- 
tion may save much disgrace and impoverishment to families, 



TEE EARLY DIAGNOSIS OF ORGANIC DISEASE. 467 

though, alas! it does not pave the way for more successful 
therapy. 

I would repeat, that a person exhibiting tremors of the facial 
muscles of the tongue and hand, a vibratory and slurred speech, 
angular or tremulous handwriting, and irregular, small pupils, 
should be suspected of having chronic peri-encephalitis or par- 
alytic dementia. The addition of gradual failure of mind — 
dementia — makes the diagnosis certain. In case there should 
be superadded exalted notions, with maniacal attacks and epi- 
leptiform seizures, the case deserves the name of general paresis ; 
and as such is the form more usually seen and studied by asylum 
physicians. 

It has been claimed in the last four years by Fournier and 
others that cerebral syphilis, in the shape of arteritis, partial 
arachnitis and localized peri-encephalitis, might give rise to the 
symptoms of paralytic dementia. I am in accord with Dr. Julius 
Mickle and others in believing that it is often possible to dis- 
tinguish the idiopathic from the syphilitic dementia. The latter 
is, comparatively, much more acute (or rather less chronic), in 
its development ; in it we do not observe the very fine muscular 
tremors as an early symptom ; the pupillary disturbance consists 
usually of mydriasis of one side, with or without other signs of 
third-nerve palsy ; the speech defect is a coarse thickness in 
pronunciation, rather than a vibratory, tremulous sound, which, 
when once heard, can never be forgotten. There are well- 
marked paralytic symptoms, usually hemiplegic, and decided 
epileptic phenomena in syphilitic cortical diseases. The de- 
mentia is seemingly more profound, causing an apparent imbe- 
cility with want of control over the sphincters. Altogether, 
the symptom group is much more threatening in appearance ; 
yet great improvement, or even apparent cure, may be obtained 
in very bad cases by the use of mercury and by heroic dosing 
with iodide of potassium. This therapeutic proving of a disease 
is of course valuable in practice, but logically it cannot be 
termed a diagnosis, and it is a reproach to the present state of 
our science that in several types of disease we should be obliged 
to resort to it. 

III. The third organic disease of the nervous system which 
should, it seems to me, sometimes be recognized with positive- 
ness much earlier than it now is, is tumor of the train. 

In making this statement I am perfectly aware that some 



468 THE EARLY DIAGNOSIS OF ORGANIC DISEASE. 

cerebral tumors produce no distinct or special symptoms during 
life, and that others produce incongruous and apparently para- 
doxical symptom groups. Some years ago, before the physiology 
of the brain was as well understood as it is now, we could offer 
no explanation of these perplexing cases, which seemed to 
destroy our rules of diagnosis. To-day we have acquired an 
approximately correct knowledge of which portions of the brain 
(cerebrum especially) are excitable and capable of causing 
symptoms, and which are inexcitable and may be the seat of 
extensive disease without clear indications. This I say without 
reference to the finer localization theories of the last five years. 
We know quite positively, for example, that extensive lesions may 
exist in the anterior and inferior portions of the frontal lobes, 
in the sphenoidal lobes, and in the occipital lobes of the cere- 
brum, and in one-half of the cerebellum, without causing any 
symptom specially useful for diagnosis, such as will be consid- 
ered later on. We have also learned, from Flechsig's researches, 
that the decussation of the motor tract, just below the anterior 
pyramids of the medulla oblongata, is variable in amount, and 
that in some cases there may be no crossing of fibres, or hardly 
any. This important law of variability in the pyramidal decus- 
sation enables us to correctly appreciate the rare cases in which 
a cerebral lesion produces symptoms (paralysis or spasm) on 
the same side of the body as itself — cases which have been so 
urgently pressed upon the profession by Brown-Sequard in the 
last ten years as proofs that our physiological laws of cerebral 
action and of the productions of symptoms were all wrong. 
These laws stand to-day, I believe, only strengthened by the 
exceptions which have been adduced. 

All I wish to say is, that tumors located in what we now term 
the excitable region of the cerebrum, or the motor zone, are 
capable of very early recognition. 

The region which receives the name of motor zone is irregular 
in shape, and perhaps its limits are not yet well ascertained. In 
a general way we may say that it includes the median region of 
each hemisphere, in particular the posterior extremity of the 
third frontal convolution, the upper half of the second and first 
frontal, the ascending frontal and ascending parietal convolutions, 
the anterior gyri of the island of Eeil, the paracentral lobule on 
the inner surface of the hemispheres, and, perhaps, a large part 
of the upper set of parietal convolutions. These are the motor 



THE FAULT DIAGNOSIS OF OBGAXIC DISEASE. 469 

convolutions, and embrace the so-called motor centres of Ferrier. 
Besides, we must include under the name of motor zone, or 
region, those fasciculi of white substance which connect the 
above-mentioned gyri with the crura cerebri, constituting the 
anterior half (or less) of the internal capsule as it passes between 
the nucleus lenticularis on the outer side and the nucleus 
caudatus and thalamus opticus on the inner side. 

The succeeding remarks apply to tumors which involve any 
of this large expanse of cerebral substance, either in its external 
gray matter or in the fasciculi of white substance lying between 
the motor convolutions and the central gray bodies. 

The symptoms which I think are characteristic of tumor in the 
motor zone of the hemispheres are : 

Localized convulsions in peripheral muscles ; equally local- 
ized paralysis of peripheral parts ; neuro-retinitis or choked 
disk ; localized headache. The symptoms are named in the 
order of their frequency and importance. 

The initial convulsions of cerebral tumor are sometimes 
restricted to one side of the face, one hand, or even two fingers, or 
one leg. The spasm is usually tonico-clonic, but may be wholly 
clonic or jerky. In many cases this localized spasm is unac- 
companied by loss of consciousness or vertigo, and it may 
remain localized in the part first affected during many attacks, 
extending over weeks and months of time. The patient feels the 
muscular contraction before it becomes evident, thus constitut- 
ing a sort of aura. In some cases almost from the first, in nearly 
all cases after a while, the convulsion involves more muscles on 
one side of the body ; it seems to ascend or descend, to use the 
patient's expressions, and there results a hemiplegic epileptic 
attack with loss of consciousness. Again, the attack may begin 
in a small peripheral part, involve the whole of one side of the 
body, and later affect the opposite side, thus constituting a full 
epileptic attack. The patient is able to watch the progress of 
the spasm for a number of seconds or minutes before losing con- 
sciousness, or being thrown down, and we may take advantage 
of this peculiarity to instruct the patient in the use of the tour- 
niquet or bracelet, placed on the limb just above the seat of first 
spasm, to cut short the attack by pressure. 

This distribution of spasm, and its possible occurrence without 
loss of consciousness, are signs which most positively distinguish 
these symptomatic convulsions from the ordinary epilepsy which 
we constantly encounter. 



470 THE EARLY DIAGNOSIS OF ORGANIC DISEASE. 

As early as 1827, a French physician, Bravais, described the 
hemiplegic form of epilepsy, and showed its relation to gross 
cerebral disease ; but it is to Hughlings Jackson, of London, 
that we owe the physiological study of these cases, and of cases 
of more limited epilepsy, and the first demonstration of the 
dependence of localized spasms upon limited lesions of the 
opposite cerebral hemisphere. 

Indeed, in prosecuting these clinical and post-mortem studies, 
Hughlings Jackson laid the foundation for the vigorous hypothe- 
sis of cerebral localization, as Ferrier states in the dedication 
of his book on the " Functions of the Brain," to this illustrious 
physician. So far as my own experience goes, autopsies have 
invariably verified the theory of localized epilepsy which I have 
stated, and the journals of the last five or six years contain 
numerous corroborative cases. As the evidence now stands, 
chronic localized convulsions must be looked upon as almost 
positive indications of a localized lesion in the opposite cerebral 
motor zone, most probably a tumor. 

"What I have said of localized convulsions applies to localized 
paralysis. It, like spasm, may be limited to a small muscular 
group, or to one half of the body ; it may begin in a part and 
gradually extend. In general terms, paralytic phenomena follow 
in the wake of the convulsions at a distance of weeks or months, 
and have the same distribution. 

Neuro-retinitis, or choked disk, is a frequent result of tumor 
within the cranium, but this symptom may, on the one hand, be 
absent with a large or even monstrous cerebral sarcoma, and 
on the other, it does not afford any indication of the locality 
of the tumor. The notion which was current a few years ago, 
that neuro-retinitis was pathognomonic of cerebral tumor, is 
wholly without foundation. 

From my observations I am led to conclude that the occur- 
rence of localized convulsions and paralysis, without choked 
disk, is valuable evidence of tumor, while choked disk without 
localized spasm and paralysis is merely a basis for suspecting 
tumor. The association of the two sets of symptoms makes up 
almost positive proof of the existence of a neoplasm. A diag- 
nosis based on this symptom group is quite as secure as that of 
any other disease giving rise to local physical signs. 

The value of headache, or localized cranial pain more strictly 
speaking, is also variable. By itself it is not strictly indicative 



THE EARLY DIAGNOSIS OF ORGANIC DISEASE. 471 

of tumor, but with either the choked disks or with localized 
motor disturbance it becomes highly significant. 

The co-existence of the three symptoms justifies a positive 
diagnosis of cerebral tumor. 

Had I more time I should like to speak of the possibility of a 
still finer diagnosis in cases of tumor of motor districts of the 
brain. We are sometimes enabled, through recent advances in 
experimental physiology and pathological anatomy, to localize 
tumors within an inch or two of their actual situation, in the 
regions known as centres for speech, centres for the face, centres 
for the arm and hand, centres for the le^, and centres for both 
arm and leg. The future of neurological medicine is pregnant 
with discoveries in this direction, which will have very prac- 
tical application. 

My purpose in embracing the opportunity of addressing you 
was to make a sketch of the scientific and logical basis for prog- 
ress in the direction of early diagnosis. 

The affections whose semeiolosfv we have studied — cerebral 
tumor, paralytic dementia, and posterior spinal sclerosis — are as 
yet incurable. Yet, if we can ever hope to apply remedies to 
them successfully, it will have to be done at the earliest moment 
when their recognition is possible by the general practitioner, 
who naturally has charge of the cases in their incipience. 



BEPORT ON THE USE OF HYOSCYAMIA AS AN 
HYPNOTIC AND DEPKESSO-MOTOR* 

I have been instructed by the Committee on Neurotics to pre- 
sent a summary of the experience of its members with that 
powerful and seldom-used alkaloid — hyoscyamia. Due credit 
will be given at the proper place to the gentlemen who have 
contributed observations. 

The report is divided into four parts. 1. A brief and, I must 
add, an incomplete sketch of the history of our knowledge of 
the drug, and a summary of the conclusions of the few physi- 
cians who have employed it. 2. A relation of our own cases 
testing the value of hyoscyamia as an hypnotic. 3. A relation 
of the cases showing the power of hyoscyamia as a depresso- 
motor or paralyzant. 4 Our provisional conclusions respecting 
its utility and the best modes of its administration. 

I. HISTORICAL. 

Hyoscyamia in an impure form was discovered by Peschier, in 
1821, f and by Brandes about the same time. 

In 1833, Geiger and Hasse X found the pure solid alkaloid very 
much like the one we now use. 

They determined its molecular constitution to be : 

Hyoscyamia = C 15 H^ N 3 , 

and this formula is accepted as correct even by the latest authori- 
ties. § By the same chemists it was shown that Hyoscyamia 
might be looked upon as a double body, in the same way as 
atropia, giving a formula : 

Hyoscin = C 6 H 13 N 

Hyoscinic acid = C 9 H 10 — 3 
C J5 H 23 N 3 . 



* Read before the New York Therapeutical Society, February 13, 1880. Re- 
printed from the Archives of Medicine, vol. v., No. 2, April, 1881. 

+ Annalen der Chemie und Pharmacie, i., p. 333. \ Idem, vi., p. 270. 

§ The National Dispensatory, second edition, 1880, p. 747. 



THE USE OF HYOSCYAMIA. 473 

Hyoscyamia is obtained from the leaves of hyoscyamus niger 
and hyoscyamia albus, in very small quantities ; according to 
Schoonbroodt, about 0.164 per cent.; according to Wadgymar, 
0.143 per cent., and according to Thorey (using the dried leaves 
picked before flowering), 0.188 and 0.208 per cent.* These 
experimenters and Merck, of Darmstadt, have greatly improved 
the processes for extracting the alkaloid. 

In our market Hyoscyamia is found in two forms — both of 
Merck's manufacture : 

First, a colored resinous extraction which is quoted at $2 a 
gram. 

Second, a white crystallized, or semi-crystallized substance, 
very pure and exceedingly powerful, which costs, at wholesale, 
$11 a gram. 

Both these forms of Hyoscyamia are dispensed by our leading 
pharmacists, and two firms supply reliable pills made of the 
crystallized form. Messrs. Caswell, Hazard & Co. offer it in the 
shape of tablets, each containing .0012, and Messrs. McKesson 
& Bobbins make little pills, each containing .0012. Both of 
these preparations have been found reliable by your committee, 
the tablets of the first-named firm seeming to be a little stronger. 

One of our number, Dr. Ball, has employed an amorphous 
preparation by Keith ; a substance whose physiological prop- 
erties are not well understood, and which may be a resinoid 
instead of an alkaloid. 

The mode of administration will be stated in connection with 
the work of each observer. 

I have consulted the following writings on Hyoscyamia : 

The essay of Oulmont on the use of Hyoscyamia in paralysis 
agitans, tremors, etc., I have been unable to find, and have not 
even seen an abstract of it. 

John Harley : " The Old Vegetable Neurotics," London, 1869, 
p. 321. 

Dr. Harley' s experiments with hyoscyamus and hyoscyamia 
are replete with interest. He used the tincture, succus, and 
solid extract of hyoscyamus, and made for himself a brownish, 
semi- crystallized sulphate of hyoscyamia. He experimented on 
mice, cats, dogs, and on man. The following are some of his 
conclusions : 

* Cited by A. and Theo. Husemann, "Die Pflanzenstoffe," pp. 478, 9. 



474 THE USE OF HYOSCYAMIA. 

1. Hyoscyamia differs somewhat from atropia, in not acceler- 
ating the pulse as much, and by a greater effect on the cerebrum 
and the motor centres. 

2. Small doses will reduce the pulse-rate by 10 or even 30 
beats. Larger doses cause a rise. 

3. Sleep and great muscular relaxation are produced. To 
cause sleep, 45 cc. of the succus hyoscyami or 30 cc. of the 
tincture are required, and from .002 to .008 grain of hyoscyamia 
(hypodermically) will do the same. 

4. In one case .50 of the solid extract produced a busy delirium 
not unlike that caused by hemp. The effects of Hyoscyamia are 
very like alcoholic intoxication. 

5. Its action on the cerebrum is very similar to that of opium, 
except that it does not cause excitation of motor centres. No 
antagonism exists between the two. 

6. Clinically, it is useful as a sedative to the heart. It is use- 
less in convulsive affections. (In view of our own experience 
this last statement seems unaccountable.) 

7. Hyoscyamia is excreted through the kidneys. 

A. and Theo. Husemann, "Die Pflanzenstoffe," Berlin, 1881, 
p. 475, These authors give an excellent pharmaceutical account 
of the alkaloid, a rather meagre summary of the physiological 
researches of Schroff, Lemattre, Buchner, Fronmuller, Diilln- 
berger, etc. 

Their conclusion is that the action of hyoscyamia is qualita- 
tively similar to that of acropia. Its chief use is as an hypnotic. 

Schroff thought hyoscyamia produced more complete and 
permanent dilatation of the pupil than atropia. 

Dr. Bobert Lawson, Assistant Medical Officer to the "West 
Biding Asylum, has contributed to the celebrated medical 
reports of that institution two elaborate papers on hyoscyamia ; 
one, " On the physiological actions of hyoscyamine," appeared 
in the fifth volume, 1875 ; and the other, entitled " Hyoscyamine 
in the treatment of some diseases of the insane," in the sixth 
volume, 1876. 

The following are some of the conclusions reached by Dr. 
Lawson in his first or physiological study. He used an amor- 
phous hyoscyamia made by Messrs. Smith, of Edinburgh — 
evidently a weaker preparation than Merck's : 

He found hyoscyamia to be more hypnotic and more diuretic 
than atropia. 



THE USE OF HYOSCYAMIA. 475 

- Very rarely there occurred a rash on the face and forearms 
not unlike measles. 

Small doses of hyoscyamia at first reduced the pulse rate, 
increasing the arterial tension, then excited the circulation. The 
axillary temperature fell 0.3° C. 

Large doses caused immediate rise of pulse, delirium, motor 
paralysis, sleep, and produced diuresis. 

Dr. Lawson's conclusions in his second or clinical study are : 

Hyoscyamia is useful in cases of insanity with delusions of 
suspicion and in mischievous cases. 

Remarkably good results are obtained in the status epilepticus. 

In the excitement of general paralysis large doses, .015 and 
.03, are required and do good. 

Small doses are efficacious in chorea and in locomotor ataxia. 

Hyoscyamia is useless in acute melancholia, in acute mania 
with delusions of suspicion, and should be avoided in furious 
mania. As results of the long-continued use of small doses of 
hyoscyamia he observed impairment of appetite, but not much 
dryness of the throat. He employed Merck's amorphous 
alkaloid (extractive), given in the following formula : 

I£ . Hyoscyamise, .045, 

Spfc. etheris, .25, 

Spts. vini rect., 1.2, 

Aquse font., [ad. 62.cc— -ft. haustus. 

I might also mention that Dr. W. Bevan Lewis, assistant med- 
ical officer to the West Hiding Asylum, in a paper upon " Calor- 
imetric observations upon the influence of various alkaloids on 
the generation of animal heat," published in W. R. Asylum 
Medical Eeports, "Vol. YL, for 1876, makes the following state- 
ment respecting hyoscyamia (page 51) : 

Hyoscyamia in small doses diminishes heat-formation, while 
in large doses it greatly increases it. 

Gubler, "Lecons de Therapeutique," Paris, 1877, pp. 138, 9, 
refers very briefly to hyoscyamia. It causes less delirium, and 
more often a natural sleep than do atropia and daturia. 

Eefers to Oulmont's use of hyoscyamia for various tremors. 

Denies that it is to be had in a pure state. 

Nothnagel and Eossbach, "Handbuch der Arzneimittelehre," 
1878, p. 666, state that its physiological action is similar to that 



476 THE USE OF HYOSCYAMIA. 

of atropia, and refer to its use in tremors. They say nothing 
of its use as a narcotic. The dose is the same as that of atro- 
pia. 

Wood, "A Treatise on Therapeutics," 1880, does not state 
doses for internal administration. He does not believe that any 
difference between the action of belladonna and hyoscyamia has 
been proven. 

Bartholow, " Materia Medica and Therapeutics," 1880, gives a 
fair account of physiological actions of hyoscyamia, but is not 
sufficiently explicit in giving doses of the two kinds. Strangely 
enough he classes hyoscyamia among excito-motors. 

Stille and Maisch, "National Dispensatory," 1880, pp. 747-9, 
give a good account of hyoscyamia, clinical and physiological. 
Its action on the spinal cord is paralyzing, like that of conium. 
They refer to Lawson's use of it in mania. Dose, .001 repeated. 
In violent excitement, up to .06. 

A more recent article is one by Dr. Geo. H. Savage, of Beth- 
lehem Hospital, in the Journal of Menial Science for July, 1879. 
Dr. Savage does not like hyoscyamia in the treatment of 
psychoses, but apparently largely because of certain preconceived 
general views against neurotics. He admits the quieting and 
hypnotic influence of the crystallized and the amorphous hyoscy- 
amia, and he gives preference to the amorphous. The former 
he gave in doses of .0025 or .004, and the latter in doses of .008 
to .06. In many of his cases anorexia was produced ; in a few, 
collapse. In melancholia harm is done by hyoscyamia. This 
alkaloid is only good to secure temporary quiet and sleep. 

Lastly, Dr. Prideaux, assistant physician to the Friends' 
Betreat, York, in several numbers of the Lancet for September 
and October, 1879, has summed up his experience with this 
drug. He noted the usual differences between small and large 
doses, viz. : small doses reducing the pulse-rate and cerebral 
excitement, followed by motor paralysis and sleep ; large doses 
cause an immediate acceleration of the pulse, reduce the tem- 
perature, and produce profound sleep. Death may be produced 
by paralysis of the respiratory centre. Dr. Prideaux used 
hyoscyamia in several forms of mental disorder, and in the 
status epilepticus, and reached the following conclusions : 

1. In most cases of mania, or where there exists great excite- 
ment of any aggressive or destructive character, or rapidity of 
movement and speech, the use of the drug is the most effectual 



THE USE OF EYOSCTAMIA. 477 

and rapid means of exercising that form of restraint which has 
been known as " chemical restraint." 

2. That in cases of acute mania it will produce sleep and 
quietude when all other drugs have failed, and is one of the 
most rapid and reliable narcotics which we possess. 

3. That in the treatment of the epileptic status in epileptic 
mania, it diminishes the number, frequency and severity of the 
attacks, especially if its administration be extended over some 
time. 

4. That in delusional insanity, especially in the mania of 
suspicion, . and in other forms of mania where the delusions 
are varying and changeable, it has a decided action in producing 
such an altered condition of the cerebral status that a condition 
which has been called " physiological mania " results, and this 
so eclipses the former delusions and hallucinations that they 
are forgotten, and the mind becomes clear ; while if the sub- 
jection to the influence of the drug be continued, it ultimately 
leads, under favorable circumstances, to a permanent condition 
of quiescence and restoration to a healthy frame of mind. 

5. That in chronic dementia, associated with destructive 
tendencies, bad habits and sleeplessness, the condition of the 
patient much improves after a continued course of small doses 
of the drug. 

Dr. Prideaux also recommends that hyoscyamia be used in 
senile mania, delirium and meningitis. 

He used Merck's extractive hyoscyamia, and gave from .004 
to .03 and even .06 in solutions by the stomach. 

II. CLINICAL EXPERIENCE WITH HYOSCYAMIA AS AN HYPNOTIC. 

Dr. J. 0. Shaw, Medical Director of Kings County Lunatic 
Asylum at Flatbush, has made a somewhat extensive trial of 
hyoscyamia in cases of insanity. The following is his sum- 
marized report to your committee : 

I have always used Merck's amorphous alkaloid. 

So far I have used the medicine in about fifteen cases. 

Acute and subacute mania is the condition in which I 
expected most benefit from its use. I have also used it in 
chronic mania with excitement and destructive habits, in the 
excitement of general paretics, in the maniacal excitement 
following epileptic seizures, etc. This drug is of great ser- 



478 THE USE OF IIYOSCYAMIA. 

vice in acute mania where the patients, from loss of sleep and 
continued motion, soon become exhausted, and then follows a 
disagreeable train of symptoms, such as dry tongue, sordes on 
teeth, and perhaps diarrhoea. If the patient refuses food and 
has to be fed with the tube, this makes the state of matters still 
worse. Hyoscyamia is a remedy which obviates this very 
largely ; it is very certain in its action ; I usually begin by 
giving .015 to .03 grain by the mouth. 

The following cases are given in a condensed form as illustra- 
tions : 

Case I. — Female, aged 34. Admitted December 4, 1879, to the Kings 
County Insane Asylum. Married ; had one child 9 years ago. The attack has 
lasted two months. She has delusions of persecution; attempts to injure her- 
self and others ; talks incessantly in a loud voice ; is incoherent ; will not 
converse or answer questions ; her general health is poor ; she looks thin and 
paie ; pupils and articulation normal ; tongue clean ; does not sleep ; talks and 
screams all night; ceased to menstruate two months ago, just as attack 
began. December Gth, she begins to menstruate ; December 7th, she has be- 
come still more noisy and restless; breaks ■windows and furniture, and strikes 
herself up against other patients; throws herself on the floor or up against the 
wall, evidently with suicidal intent. Two days after, the 9th, she lias to be 
fed; tongue and lips have become dry; she talks and moves about continually. 
To-day, for the first time, we give her .03 hyoscyamia at 12 m. In one-half 
hour she was quiet. At 3 p.m. she was sitting upon a bench apparently fast 
asleep ; eyes closed and head resting on chest ; the cheeks puffed out at each 
expiration; pupils dilated ; she was profoundly under the influence of the 
drug. At 8 p.m. of the same night she was fed with the tube, but went to 
sleep again immediately after it. When she awoke in the morning she again 
became noisy ; passes her urine in her clothing. December 10th, was fed with 
tube and .03 hyoscyamia given; at 12 she was quite quiet, and ate a hearty 
supper that evening. 

Dec. 11th. .03 given this forenoon, and she slept the greater portion of 
the day. She ate her dinner, but would not eat supper. As she is feeble, 
tongue and lips dry, she is fed. At 10 p.m. she is quite noisy; she is given 
1.2 chloral and extra night-watch placed over her. She throws herself out of 
bed, and tries to strike her head against the floor and wall. 

Dec. 12th. She slept last night; to-day .03 hyoscyamia is given her; she 
slept nearly all day ; she will eat some of her meals ; tongue is now moist and 
clean ; she spits at every one who goes near her, and will not answer any 
questions. 

Dec. 13th. The .03 dose appears to have such a profound effect upon her 
that Ave give her .015, which appears to have almost as much effect as the 
.03 did. She slept almost all day; at night, gave her 1.2 chloral and a bottle 
of ale. She did not sleep; restless, and talked all night. 

Dec. 14th. Is noisy and running about. I feed her with the tube myself, 



THE USE OF HYOSCYAMIA. 479 

and give her .015 hyoscyamia; tongue is moist and clean; she was quiet after 
the medicine, but did not sleep. 

Dec. 16th. She did not sleep last night and was restless ; so this morning 
she is given .015 hyoscyamia, after which she slept. 

Dec. 17th. Noisy and excited; gave .015 hyoscyamia. 

Dec. 18th. Removes her clothing and is noisy; .015 given. 

Dec. 19th. Eats much better; has not to be fed; talks incoherently; .03 
hyoscyamia given at bed -time in a bottle of ale. Slept all night. 

.015 hyoscyamia is given every day until Dec. 27th, producing its physio- 
logical effect each time. 

On Dec. 27th none is given. 

Dec. 28th. .015 given, and every day after until Dec. 31st. 

She is much improved physically; eats her meals ; is quiet. 

The hypnotic effect of the drug is here well shown by this case, and its 
great superiority to chloral in that respect. 

Case II.— Male, aged 3G. Admitted Nov. 8th. Certificates state that he 
declares that lie is the Supreme Being; the Virgin Mary is his wife and mother. 
On admission is very noisy, shouting, clapping his hands, walks about in- 
cessantly, and behaves in a very demonstrative manner; is incoherent; talks 
about the priests, Virgin Mary, etc., in a rambling manner. 

He was given .03 of hyoscyamia, and was quiet in fifteen minutes, and the 
full physiological effect of the drug is obtained ; he sleeps profoundly for 
hours; as soon as he escapes from under the influence of the drug he is again 
noisy. 

November 12th and 13th he is given .03 night and morning; he is noisy 
just as soon as the effect passes off. 

It will suffice for me to say that the effect of the drug became more and 
more transient, and the dose was increased until, on December 2d, he took, 
at 8 a.m., .25 at one dose, the effect passing off so rapidly that at 3 p.m. he 
was again as noisy as ever; at 7 p.m. he is given .25 more, making .50 of 
hyoscyamia in one day. He no longer sleeps under the influence of the 
medicine as he did when it was first given; the medicine is discontinued as 
there is no permanent effect. During the time he was taking the large doses 
he passed large quantities of pale urine, which ceased as soon as the medicine 
was discontinued. 

December 8th, he is given .00 hyoscyamia (there has been an interval of 8 
days since he took the last dose, and he has been just as noisy and restless as 
he ever was, night and day) at 3 p.m., which in half an hour produced its 
marked imysiological effects ; but the effect of the subsequent doses becomes 
less and less marked, until on December 29th he takes .18 in the mornino- 
and .18 in the evening; .30 in the day, and as he has become so tolerant 
of it, it is again stopped. 

Case III. — A gentleman who had suffered from epilepsy for years past, has 
attacks of maniacal excitement after the fits, which will last 3, 4 days or a 
week ; nothing has ever arrested these maniacal attacks. He has a fit, and a 
few hours after he begins to shout psalms and praises to God. I gave him 
.03 hyoscyamia at 10.50 a.m ; at 11. 20. he is unable to stand ; at 11.40 can sit 
up no longer, and has to lie down, and immediately sinks into a deep sleep, 



480 THE USE OF HYOSGYAMIA. 

occasionally snoring ; pulse 88 (112 before he took the medicine) ; increased 
reflex action, pupils slightly dilated. He sleeps until 6 p.m., when lie eats 
his supper and goes to bed ; he has to be assisted to his room, as he is 
unsteady on his feet ; he sleeps all night soundly; the next morning is 
quiet, and in the afternoon is returned to the quiet hall. The attack would 
have lasted many days had we not given the hyoscyamia. This is one of the 
best results I have had with the drug. 

I have tried it in some cases of melancholia with excitement, but without 
special benefit. 

Case IV. — Dementia following mania in a man of 50. He Avas in the asylum 
20 years ago ; was admitted this time about a year ago. He w r as in the habit 
of tearing up his clothing, bedding and bed ; in fact, anything he could get 
hold of. If his hands were restrained lie would use his teeth, kick the walls 
and break the furniture. 

I gave him .06 hyoscyamia ; in half an hour after he could not stand prop- 
erly, walked about and tried to pick things off the floor, but which he was 
often unable to do ; he staggered as if he was drunk. He was evidently con- 
scious that there was something the matter with him, for when one of the 
attendants told him that he was drunk he laughed. In one hour he was com- 
pletely unable to stand, but lay down on the floor and went fast asleep. 

On the two following days we gave him .06 dose each day and then stopped. 
He never tore up anymore things, and became one of the most quiet and 
orderly men in the hall, and would help to do some of the work. 

I liave used it in numbers of other cases, and the effects have 
been alike throughout. 

The effects are temporary as a rule ; most patients become 
quickly tolerant of it, and the dose has to be increased. There 
does not appear to me to be any deleterious effect produced by 
its use. 

In acute maniacal attacks found inside and outside of asylums, 
it is undoubtedly a most valuable medicine, and certain in its 
action. 

CASES REPORTED BY DR. A. B. BALL. 

The two cases here reported illustrate the marked efficiency 
of hyoscyamia as an hypnotic in acute and subacute mania, the 
influence of the drug in controlling delusions, and its occasional 
tendency to paralyze the bladder. 

Case I. — The first case was one of acute senile mania in a gentleman sixty- 
five years of age, who had been an epileptic for years, but had had no convul- 
sions for fourteen months. For several months albumen and casts had been 
occasionally detected in the urine, and granular kidney had been suspected. 
During the attack of mania, to be described, the urine was normal in quan- 



THE USE OF HYOSCYAMIA. 481 

tity, free from albumen and casts, and no ursemic symptoms were present. 
On October 5, 1879, after having been restless and sleepless at night for three 
days, he suddenly became very violent, extremely voluble, and imagined he 
had been attacked and beaten by robbers. This delusion continued through 
the attack. Pulse and temperature normal for first three days, but both rose 
on the fourth day, and for the next fortnight the pulse ranged from 115 to 
140, and temperature from 38.4° C. to 39.7° C. On October 11th he became 
comatose, and remained so for forty-eight hours, death being almost hourly 
apprehended. He recovered from this condition, however, and gradually 
gained strength, but the delusions continued as active as ever. Chloral, 
bromide of potassium, and morphine were used to procure sleep, but with very 
unsatisfactory results. On October 25th .01 of Keith's hyoscyamia was given 
at eight p.m. and repeated at nine. After the second dose, without any 
noticeable physiological effects, except the production of sleep, patient slept 
quietly for fourteen hours. Awoke more composed and rational. The same 
doses were repeated the following night, and on awaking after twelve hours' 
quiet sleep, the restoration of the mental faculties was complete. When 
closely questioned in regard to business matters, past events of his life, the 
multiplication table, etc., his replies were entirely satisfactory. He remem- 
bered the events of the first three and last three days of his illness, but the 
rest was a complete blank. No relapse occurred, and he has since remained 
in perfect mental health. During the entire illness the patient was attended 
by Dr. Alonzo Clark in connection with myself, and was also seen in consul- 
tation by Dr. E. C. Seguin. 

Case II. — The second case was one of melancholia of several months' dura- 
tion in a gentleman about 70 years of age. Early in the morning of January 5, 
1880, after having been unusually restless by day and sleepless at night for 
several days, he attempted suicide by jumping out of the second story window. 
Falling on the balcony of the story beneath, he escaped injury beyond a few- 
trifling bruises. During the following day he was very restless and had 
delusions of persecution. At night .02 of Merck's amorphous hyoscyamia 
w r as given, and patient slept quietly for ten hours. On awaking he was much 
confused, staggered in his gait, and was unable to pass water. Catheter 
used. The symptoms of muscular paresis passed off in two hours. Patient 
more composed and rational. .01 given the next night. Slept six hours. 
Retention of urine again, but has general muscular paresis. Mental condition 
much improved. Increased appetite. During the next few days he became 
more tolerant of the hyoscyamia, and .03 doses were required to produce 
sleep, but as the medicine always produced retention of urine, it was stopped, 
and on Jan. 15th 1. of chloral with 2. of bromide of potassium were sub- 
stituted. A more restless night. At eight o'clock a.m. he sat up in bed and 
ate his breakfast, after which he lay down in bed and fell into wdiat was sup- 
posed to be a deep slumber. At nine o'clock he could not be roused, and a 
few moments later died. The cause of death was uncertain, as no post-mortem 
was allowed. Dr. Abram Du Bois attended the case, throughout the illness, 
in connection with myself. 

31 



482 THE USE OF HY0SCYA31IA. 

A CASE OF DELIRIUM TREMENS, BY DR. F. P. KINNICUTT. 

The attack occurred in a gentleman aged . . . The treatment was initiated 
on November 26, 1879, and consisted of large doses of chloral and bromide 
of potassium, with unsatisfactory result in producing sleep ; not more than 
two hours' sleep being obtained at any one time, and that of a restless char- 
acter. During the night, November 1st and 2d, he took 5. of chloral and 8. 
of bromide of potassium without ]3roducing more than a few moments' rest- 
less sleep at any one time. 

November 2d. The patient's condition is wretched. He is extremely 
restless, depressed, threatens suicide and even makes an attempt ; begs for 
stimulants. Hyoscyamia .0012 (Merck's crystallized preparation) is given by 
the mouth and ordered repeated pro re nata. 

November 3d. Passed a very good night ; sleeping several hours very 
naturally. .0012 had been repeated in the afternoon of the 2d, and .0006 
before 10 p.m. From this date there was continued and rapid improvement ; 
good nights with apparently physiological sleep. .0012 administered by the 
mouth twice a day was found to be sufficient. 

Aside from hypnotic action of the drug, the only effects observed were 
hallucinations of a pleasant kind, and slight dryness of the throat. No alter- 
ation of temperature occurred after doses. § 

CASE CONTRIBUTED BY DR. ANDREW H. SMITH. 

I was consulted by letter on January 5, 1880, in regard to the 
following case : 

E. T., aged 65. Three of his brothers and sisters died insane, two of them 
by suicide. For the past two years he has been gradually developing melan- 
cholia, recently becoming rapidly worse. He was very restless, sleepless, un- 
manageable, wandering about the house, talking wildly and excitedly. Pend- 
ing removal to an asylum I advised the administration of .0012 of crystallized 
hyoscyamia to be given night and morning. This produced sleep at night 
and rendered the patient quiet and manageable during the day, to the great 
relief of the family, to say nothing of himself. 

CASE OF MORBID DREAMS, BY DR. E. C. SEGUIN. 

A gentleman, 50 years of age, affected with paresthesia? in the head and 
tinnitus aurium, was sent to me for treatment by Dr. J. S. Jewell, early in 
November last. Mr. X. was unquestionably hypochondriacal to a certain 
extent. Many years ago he had been a dyspeptic ; he had worked unremit- 
tingly at his business for many years, and in the last ten years his head had 
become worse and worse ; insomnia had developed and he had led a wretched 
existence. His insomnia was made the more trying because what little sleep 
he obtained was troubled by fantastic and fearful visions of a panoramic 
character ; scenes of violence, obscenity, comicality, would, as it were, pass 
before him almost with the vividness of hallucinations. Indeed, he had the 



THE USE OF HYOSCYAMIA. 483 

same "visions" at any time if lie dozed for a minute in his chair. Treat- 
ment began November 14, 1879. Injections of .18 of camphor failed. 

On the loth I gave him, chiefly with the idea of procuring sleep, the 
crystallized hyoscyamia in doses of .001, by hypodermic injections, at bed- 
time. 

19th. Much better; little pressure in head for four days; less tinnitus; 
some sleep. At night, .002 of hyoscyamia hypodermically. 

21st. Depressing and fearful dreams are much less marked, though there 
was not much sleep last night. Given .0024 hyoscyamia and .009 sulphate of 
morphia under the skin . 

22d. Had a good night. 

On the 29th he was ordered one tablet of .0012 hyoscyamia at bedtime with 
opium. The peculiar dreams have almost ceased. After this date, to the 
present time, Mr. X. has used one tablet of hyoscyamia almost every night, and 
has had ugly dreams only on one or two occasions. He has used small doses of 
McMunn's elixir of opium (morphia and opium in substance caused great 
itching) and a varied restorative treatment, with marked influence upon all 
his symptoms. 

A parallelism might, I think, be drawn between this arrest of 
morbid dreams and the happy effect of hyoscyamia in cases of 
delirium tremens, delusions of persecution, etc. 



HYOSCYAMIA AS A DEPKESSO-MOTOK * 

In the preceding paper I have presented a resume of the state 
of our knowledge on the subject of the hypnotic action of hy- 
oscyamia, together with the experience of the Committee on 
Neurotics of the New York Therapeutical Society. The follow- 
ing statements are with reference to the almost equally impor- 
tant depresso-motor or paralyzing effect of the drug. 

It may be well to premise that in 1869, Dr. John Harley wrote : 
" In convulsive affections, it (hyoscyamus) has proved useless in 
my practice. The plant undoubtedly exercises a considerable 
depressing influence on the corpora striata, but it fails to dimin- 
ish the excitability of the spinal centres, if it does not actually 
exalt. ifc."f Harley, however, speaks of hyoscyamia as valuable 
in cardiac functional disorders, in neuralgia, especially visceral, 
in cardiac and pulmonary asthma. OulmontJ was more for- 
tunate in his clinical experience. He employed Merck's crystal- 
lized hyoscyamia, in doses from .001 to .003 several times a day, 
in pillular form or hypodermically, and gave enough to obtain 
full physiological effects. He treated several cases of neuralgia, 
occipitocervical, sciatic, etc., and nearly all the cases were 
cured pretty rapidly. In mercurial tremor, even in cases which 
had resisted sulphur baths and iodide of potassium, he obtained 
four cures and two reliefs. A case of progressive locomotor 
ataxia was not favorably influenced by hypodermic injections of 
hyoscyamia, excepting that the pains were somewhat dulled. A 
severe and rapidly fatal case of traumatic tetanus received doses 
which Oulmont considers to have been too small ; the pain of 
the spasms was moderate, but the tetanus remained unchanged 
(this is in accord with Harley's statements). He had no oppor- 
tunity of treating paralysis agitans, though, strange to say, he is 
often referred to as having been the first to use hyoscyamia in 
that disease ; he merely refers to Charcot's experience. 

This trial of hyoscyamia by Charcot is more explicitly stated 

* Reprinted from the Archives of Medicine, vol. v., No. 3, June, 1881. 
f " The old Vegetable Neurotics," London, 1869, p. 340. 
\ Bulletin de Therapeutique, tome lxxxiii., p. 481, 1872. 



HYOSCYAMIA AS A DEPRESSOMOTOR. 



485 



by Ordenstein in his essay on paralysis agitans and sclerosis.* 
He says : " We have yet to mention a last therapeutic experi- 
ment. M. Charcot has recently given [to cases of paralysis 
agitans] two or three grannies of about .001 of hyoscyamia per 
diem. This medicine has procured several hours of rest to a 
number of patients. New observations are requisite to enable 
us to express an opinion as to the value of this treatment." 

Dr. Lawsont thought that hyoscyamia had proved service- 
able in chorea and locomotor ataxia. 

My own experience has been as follows : 

HYOSCYAMIA IN PARALYSIS AGITANS. 

Case. — Mr. F., aged 42 years, consulted me, at Dr. Blumenthal's request, on 
May 19, 1879, and gave the following history : Good health until 1874, when 
he had a severe attack of " inflammation of the bowels'' lasting for several 
weeks. A fistula in ano formed not long afterward and has continued. With- 
out any other apparent cause he began to tremble in 1875, the fingers of the 
left hand being first affected. Not long afterward the left leg became affected, 
and in the course of two years, very gradually, the right hand and arm be- 
came involved. The symptom has steadily increased in intensity in both 






"yrz^ov ^-X*^~~fc*~>^0~tr^' 



AAAAAAAAAAAJi 



ft A A A A 



Fig. 1. 
Tracing of movements of middle tendon of the extensor communis digitorum, in paralysis 

agitans. 




Fig. 2. 

Upper tracing shows regular flexion and extension movements of the hand ; the lower, pulse- 
like tracing represents the tremor of the extensor carpi • radialis longior taken on its 
tendon : paralysis agitans. 

* Ordenstein, L. Sur la paralysie agitante et la sclerose en plaques generalisee, 
p. 31. Paris, 1868. 
f West Riding Lunatic Asylum Reports, vol. v. , 1875. 



486 HYOSCYAMIA AS A DEPRESSO-MOTOR. 

upper extremities ; the left leg is about as it was three years ago, and the right 
lower extremity is unaffected. The legs feel weak, but patient has noticed 
neither pro- nor retro -pulsion. No numbness of limbs, headache, dizziness, 
loss of memory, or affection of general health. Parents did not tremble. 

Examination. — General condition excellent. Facies is injected and exhibits 
the characteristic stare of the disease. No anaesthesia of face or hands. 
Dynamometer test of strength of grasp made useless by injury to right hand ; 
no apparent loss of power. The tremor affects the left leg (slightly) and the 
two upper extremities ; the head and right leg are perfectly still. The move- 
ment is constant, consisting of alternate movements of flexion and extension 
(mostly) made with great rapidity and with absolute rhythm. The rhythmic 
nature of the trembling is well shown in the annexed graphic tracings. Emo- 
tion makes the tremor Avorse ; it can be temporarily checked by the will, and 
co-ordination of movements is exact, i.e., there is no ataxia ; he can place a 
finger on his nose with closed eyes, and can carry a full glass of water to his 
lips. The hands when resting naturally on the knees make the well-known 
pawing movements. The normal use of the hand for eating, dressing, etc., is 
much hampered by the tremor and by a certain slowness and stiffness in willed 
muscular movements. The patellar tendon-reflex is normal, or perhaps sub- 
normal. 

It may not be uninteresting to add that Mr. F. has been under the care of 
several eminent specialists for diseases of the nervous system, two of whom 
had looked upon the disease as sclerosis of the brain and cord. (This is a 
good illustration of the foggy notions which prevail as to the meaning of the 
forms of tremor and the diagnosis of disseminated sclerosis.) He had at- 
tempted a great variety of treatment, perseveringly, without relief, by means 
of, for example, sedatives, counter-irritants to the spine, hypodermic injec- 
tions of strychnia, etc. 

I told the patient frankly that nothing would cure him, but proposed a 
trial of hyoscyamia as a means of relief. The drug was administered for sev- 
eral weeks, hypodermically, and the following are notes of effects observed. 

On May 21, 1879, I prescribed : 

I£ Hyoscyamia?, .06 

(Merck's crystallized) 
Glycerinae, 

Aquas destillatae, aa - 6.00 

Acid, carbol. pur., - - - - .03 

Mix, filter with care, and label : 

"Hyoscyamia solution for hypodermic use, .06 = .0003." 

This prescription was dispensed by Messrs. Caswell & Hazard, and in the 
afternoon of the same day I gave the patient an injection of .0012 in the arm. 
In the course of half an hour all tremor had ceased, the mouth was parched, and 
the pupils somewhat dilated. In an hour after the injection, the patient was 
greatly distressed by dilatation of the pupils and dimness of vision, by extreme 
dryness of the mouth, causing almost complete aphonia ; and there was slight 
delirium. Four hours after the injection, these symptoms had in a great 



HYOSCYAMIA AS A DEPRESSO-MOTOR. 487 

measure passed away, out the hands were still absolutely quiet, and the tremor 
only very gradually reappeared during the ensuing two hours. 

Thus .0012 of hyoscyamia produced a complete cessation of the tremor 
for a period of at least four hours ; a result which was as surprising as it was 
gratifying to me, whose experience had been that no means known to our 
art, short of complete anaesthesia, were capable of arresting this trembling. 

On subsequent days I injected from .001-. 0012, with invariably the same 
results. In a week or two a certain degree of tolerance was established, and 
.0012 did not produce much distress, but still suspended the movements of 
the paralysis agitaus for two or four hours. 

The patient, and his relatives also, noticed that going up and down stairs, 
using hands for buttoning his clothing, feeding himself, etc., became much 
easier, and he felt stronger. 

While the daily hypodermic injection of hyoscyamia, once a day, thus 
caused very great temporary relief, and produced a certain amount of posi- 
tive continuous improvement, there were no unpleasant effects of any im- 
portance. The digestive organs remained in good condition, the accommoda- 
tion was not wholly paralyzed, no abscess or special irritation was produced 
by the injections. 

Early in July, pills containing .002 of hyoscyamia were substituted for the 
injections, with equally happy effect ; two pills a day giving the patient sev- 
eral hours of absolute freedom from tremor, without unduly severe toxic symp- 
toms. During the month of August the patient became more sensitive to 
the drug, and the doses were reduced to .002 in the morning, and .001 in the 
afternoon. The paresis of accommodation varied somewhat from time to 
time, but was easily corrected by weak convex glasses. Prof. H. Knapp was 
consulted upon the question whether permanent injury to the eye might result 
from the long-continued or indefinite use of the medicine, and he replied that 
it could not. 

The patient returned to his home in Louisiana, in September, taking with 
him a number of pills made at my request by Messrs. McKesson & Robbins, 
each containing .0012 of hyoscyamia. 

I have since indirectly heard that the disease has made progress. 

I have used hyoscyamia in several other cases of paralysis 
agitans, and always with the same effect, viz., temporary relief. 
The drug has been given in these other cases by the mouth 
using the tablets of .0012, made by Messrs. Caswell & Hazard. 
One tablet in the forenoon and one at bed-time have been suffi- 
cient to almost arrest the trembling for a period of time varying 
from one to three hours, and to cause a delusive sense of im- 
provement throughout the period of treatment. After a few 
weeks, on omitting the drug, it was observed that the tremor 
was as before. Indeed, I should add that in all my cases the 
usual progressive development of the disease has not been pre- 
vented. 



488 HYOSCTAMIA AS A DEPRESSO-MOTOR. 

Still it is a real addition to our therapeutics to have a drug 
which cau, for a few hours, afford physical rest to a patient tor- 
mented by paralysis agitans. The hypodermic injection of .0006 
to .001 will surely do this ; and the internal administration of 
from .001 to .002 will produce a similar less-prolonged suspen- 
sion of tremor. 

HYOSCYAMIA IN CHOKEIFOKM AFFECTIONS. 

Case I. — Co-ordinated rhythmical hysterical spasm (hammer- 
ing or pounding chorea). 

Mrs. K., aged about 28 years, was placed under my care during the latter 
part of June, 1879. I learned that she had been hysterical for many months ; 
having weeping, globus hystericus, at times pseudo-coma with rigidity, and 
nearly constantly of late a peculiar spasmodic affection which will be described 
in detail. This spasmodic movement was at the time I saw the patient 
almost the only symptom present. Appearing late in the winter, it had 
changed its character and rhythm a good deal, but had never been completely 
suspended. Mrs. K. had suffered from no corporeal disease, except what, 
from the imperfect account I received of it, may have been imperforate 
hymen, which had been successfully operated during the spring by a prom- 
inent gynecologist. 

When I first saw Mrs. K., she was sitting up in bed, looking pale, but not 
much emaciated ; her eyes were bright, and she was perfectly clear-minded 
and reasonably calm. A pillow lay u]3on her knees, and she was pounding it 
with her two closed fists, with a regular up-and-down stroke. The blows 
were quite hard, given with perfect rhythm, both hands coming down to- 
gether, at the rate of one hundred strokes per minute on the average. There 
was no marked motion above the elbows ; it was a regular hammering or 
pounding. The excitement of the examination momentarily increased the 
rate of hammering, and this also occurred on one side when the other hand 
was forcibly held by the observer or kept still by volition. The will could for 
a few moments suspend the movements, but the effort caused distress, and 
was followed by increased rapidity and force of striking. The noise made by 
the pounding could be heard a long distance, and on several occasions, when 
the pillow had slipped out of position, Mrs. K. had bruised her knuckles. 

I was informed that this extraordinary performance was kept up all day 
and evening, until sleep supervened. The trained nurse in attendance esti- 
mated that the pounding was done for fourteen hours on some days, and 
eighteen hours on others. A simple calculation will show that from eight to 
ten thousand double blows were struck each day by this lady. There was no 
apparent fatigue from this wonderful expenditure of motor force; and several 
times visiting the patient late in the evening I found her nearly as* fresh-look- 
ing and as amiable as in the morning. She was tastefully dressed nearly the 
whole day, but sat on a lounge and occasionally took a few steps around the 
room, hammering all the time. 



HYOSCYAMIA AS A DEPRESSO-MOTOR. 489 

Occasionally, almost each day, the hammering ceased, and was replaced by 
tetanic rigidity of the extremities and trunk, with or without seeming coma : 
sometimes with emotional excitement. 

I made a thorough examination of the patient, except, owing to the patient's 
refusal, of the sexual organs, with a negative result. The urine was especially 
examined and found free from signs of renal disease. 

The case, after making marked progress in relation to the hysteria and the 
special spasms, terminated in a most tragic manner during my absence from 
New York one Sunday, by uraemic convulsions and coma. A 'post-morUm, study 
of the urine showed albumen, hyaline and granular casts. 

I desire to report the effect of hyoscyamia upon this choreiform affection, 
premising that no medicine tried by the several physicians who had treated 
the case before me had arrested the hammering. 

The solution employed was that for which a formula is given. On June 
28th, at 1 p.m., I injected .0006 of the solution under the skin. At 1.40 there 
was marked flushing of the face, dilatation of the pupils, dryness of the 
mouth; the pulse unaffected, beating sixty-five per minute. The hammering 
was reduced to the slightest bloics, given with great regularity. This reduction 
of the spasm occurred very gradually, from very hard pounding at the rate of 
more than one hundred blows per minute. The patient complained of a sense 
of weakness in the arms, and of drowsiness, and fell asleep for three hours. 
The pounding did not reappear until some time after waking, and then it was 
weak. At 9 o'clock p.m. I made a second visit, and found the patient com- 
fortable — pounding very gently. I then injected about .0005, with the same 
gratifying results, viz., moderate toxic effects, and complete cessation of 
spasm with good sleep. 

These effects were regularly obtained each day for a fortnight, but a*t the 
end of that time it became evident that the effect of hyoscyamia was only a 
palliative, as in paralysis agitans. 

Case II. — Chronic chorea in the adult. Male, aged 45 years; employed as 
a helper at a railway depot for the past twelve or fourteen years ; has been the 
subject of most marked general chorea. During these years he has had choreic 
movements affecting the extremities, neck, face, tongue, jaws, etc., — in brief, 
the whole body. In the last few years sleep has been greatly interfered with 
by the continuance of movements at night. Even when asleep, he has jerked 
about in bed to such an extent, striking out with his arms and legs and grat- 
ing his teeth, that his wife had been unable to occupy the same bed. 

Examination showed only common chorea. No paralysis, anaesthesia, or 
other signs of organic disease of the nervous system. Speech affected as in 
common chorea, not as in sclerosis. Facies and manner somewhat demented. 
Intelligence fairly preserved. Examination is made difficult by extreme 
choreic disorder. 

January 7, 1880, he received .0006 of hyoscyamia, hypodermically, at 9 p.m. 
The only effects were considerable dryness of the mouth and some incoher- 
ence in the night. 

January 8th. At 10.10 a.m., pulse, 74; axillary temperature, 36.5° C. ; 
respiration 20; pupils, 4 mm. diameter. Can hardly keep feet and hands 
still an instant. The mouth and tongue are in such constant motion that it is 



490 HYOSCYAMIA AS A DEPRUSSO-MOTOR. 

impossible to take temperature in the mouth. Administered .0008 of hyoscy- 
amia. 

At 11.10 a.m is sound asleep and perfectly quiet ; a state of things not 
seen in the last eight years. Pulse, 82; pupils contracted. After being 
awakened he remained fairly quiet, and would protrude the tongue, a thing 
impossible before. Pulse then, 90; skin, warm; and axillary temp., 36.7° C. 
Pupils, wider. From this time on, the administration of .0015 morning and 
evening kept the chorea almost completely in abeyance, and procured good 
sleep. The drug began to affect him in about half an hour, and in two hours 
a maximum effect was reached. 

Later, for a day or two, the dose was increased to .002 and even .003. The 
chorea was completely suspended by these doses, but excessive dryness of the 
mouth and nausea were produced. 

Once the treatment was suspended for forty-eight hours. The chorea 
returned to a moderate extent. Later, the use of hyoscyamia was wholly 
suspended, partly because of nausea and also because of the 'addition of Fow- 
ler's solution to the treatment. The arsenic was given hypodermically twice a 
day, in doses of .60 finally. Some toxic effects were manifested. About 
March 1st the patient returned to his home in the country decidedly improved, 
and was able to resume work. He was seen in the middle of March, 1881, 
and proved to be very much less choreic than when treatment was instituted. 

During the course of the treatment by means of hyoscyamia a number of 
observations on the pulse, respiration, and temperature were made, with the 
same result as on the first two days. Two experiments were also made with 
the view of determining whether the patellar tendon-reflex was affected by 
the drug. On February 13th at 9 A. m. the reflex was found normal. Ad- 
ministered .002 hyoscyamia under the skin. In half an hour there was great 
dryness of the mouth, dizziness, staggering, and sleepiness. Went to bed 
and slept soundly for two hours without a movement. Awoke, talked in a 
flighty manner, and went to sleep again. Was seen at 2 p.m., still moderately 
under the influence of the drug ; tendon-reflex at knees, normal. At 5 o'clock 
p.m., reflex normal. Gave. 002 again, with full physiological effects. In this 
condition, extreme dryness of mouth, dizziness, staggering gait, hallucination 
of hearing (heard a cat), great congestion of face and neck, violent headache," 
and dilated pupils ; knee reflex remained normal. 

I am indebted to Dr. R. W. Amidon for the details of this observation. 

In many «of the reported cases of mania treated by means of 
hyoscyamia, whether given by the mouth or hypodermically, 
muscular relaxation is mentioned as a prominent symptom 
following a full dose. (Vide cases by Dr. Shaw, p. 477.) 

These cases demonstrate, it seems to me, that hyoscyamia is 
a powerful and constant depresso-motor or anti-spasmodic. 
The spasmodic movements of paralysis agitans, of hysteria, of 
chorea, can be completely arrested by it for several hours. The 
power of retaining the erect or sitting posture may also be 



HYOSCYAMIA AS A DEPRESSO-MOTOR. 491 

annulled by hyoscyamia. These facts and Dr. Amidon's 
observations on the state of the tendon-reflex during the toxic 
state produced by hyoscyamia would seem to justify the con- 
clusion of Dr. John Harley, cited at the opening of this paper, 
that the " plant undoubtedly exercises a considerable depressing 
influence on the corpora striata, but it fails to diminish the 
excitability of the spinal centres, if it does not actually exalt it.' 
The experience of all observers, with reference to the phys- 
iological and therapeutic effects of hyoscyamia, may be summed 
up as follows : 

1. It acts as a mydriatic, but whether more fully or longer 
than atropia remains to be settled. 

2. When given in small doses it reduces the cardiac pulsa- 
tions, increases arterial tension, and checks the loss of body 
heat. It also produces hallucinations and delirium. It may 
cause a fall of axillary temperature, and occasionally a rash. 

3. In large doses it immediately increases the pulse rate, pro- 
duces a seeming paralysis or motor debility, and sleep. 

4. Hyoscyamia is indicated in mania, restlessness, delusions 
of persecution, dementia with agitation and destructiveness, 
epileptic mania, insomnia, rapid action of the heart, epilepsy (?), 
status epilepticus, chorea, paralysis agitans, hysterical spasms, 
tremor, neuralgia, etc. 

5. In mania and allied states it produces sleep as certainly, 
or even more certainly, than chloral, without any evil after- 
effect, unless it be occasional gastric disorder. 

6. In cases of delusions of persecution cr of suspicion it has 
produced a positive cure. 

7. In paralysis agitans it achieves what no other remedy ever 
has done, viz., it arrests the movements for four hours or more 
without producing insensibility. 

8. In the status epilepticus it shortens the attack materially ; 
perhaps better than any other single remedy. 

9. It is a diuretic of no mean power. 

10. The curative power of hyoscyamia does not appear to be 
great. In some cases of insanity its use has been followed by 
recovery ; but, as a rule, we must look upon it as a good narcotic, 
often speedier, more complete, and less objectionable than 
morphia and chloral hydrate. 

11. In spasmodic diseases, so far, we can speak of hyoscyamia 
only as an ameliorating agent, or as a palliative. 



492 ACONITIA IN POSTERIOR SPINAL SCLEROSIS. 

I would suggest, lastly, that in cases of very acute chorea, 
where death is threatened by incessant motion, hyoscyamia, 
given hypodermically, may prove of benefit by securing muscular 
relaxation with certainty, thus allowing the patient to rest, and 
giving time for other remedies to act. 



THE PHYSIOLOGICAL EFFECT OF ACONITIA IN 
POSTEKIOE SPINAL SCLEKOSIS : CAN IT BECOME 
AN AID IN DIFFEKENTIAL DIAGNOSIS?* 

I have observed in six well-marked cases of posterior spinal 
sclerosis, in the first and second stages, a remarkable resistance 
to the action of aconitia as shown by numbness of the periphery. 

These six patients took large doses, of the alkaloid, from three 
to six tablets of .0006 each, in a day, without numbness in the 
ataxic or neuralgic parts. Numbness showed itself in the parts 
of the body above the supposed seat of sclerosis, and several of 
the patients felt faint, dizzy, and quite sick from the medicine. 

Dr. W. R. Birdsall, at my request, administered aconitia in 
full doses to several ataxic patients under his charge with sub- 
stantially the same effect ; one case experienced no tingling ; 
another case had a little numbness in toes ; and a third case, 
after taking four doses of .0006, used at intervals of three hours, 
felt some numbness in ends of fingers ; a few hours later was 
"numb all over." 

It appears from these nine cases that tabetic patients are pe- 
culiarly insusceptible to the characteristic sensory disturbances 
produced by aconitia. This resistance, apparently absolute in 
some cases, is shown in the first stage of the disease. One of 
the cases, which took at one time .01 of aconitia in less than forty- 
eight hours, was examined post mortem, and the cord found 
sclerosed. The aconitia used in these tests was Duquesnel's 
crystallized aconitia, prepared by Caswell, Hazard & Co., in 
tablet form. The specific effects of these tablets were obtained 
during the same period in other cases of disease and in healthy 
patients. For example, in my own case, .0006 at 10 A.M. and at 
12 noon, made me numb from head to foot, and chilly for nearly 
five hours. 



* Read before the American Neurological Association. June 17, 1881. Reprinted 
from the Journal of Nervous and Mental Disease, July, 1881. 



DIPHTHERITIC ATAXIA AND PARALYSIS. 493 

While not now prepared to advance a theory of the manner in 
which sclerosis of the posterior columns prevents the sensation 
of tingling and numbness in tabetic patients charged with aconi- 
tia, I feel confidence in my facts, and would offer them as con- 
stituting a new negative test or symptom of the disease. 

Either there is an unknown lesion in the gray matter in ataxia, 
and in that gray matter the passage of the abnormal sensation 
is interfered with ; or, second, that the drug does not act upon 
the gray matter, but upon the nerve fibres, and as these are dis- 
eased, the sensations do not arise. 



A CASE OF DIPHTHERITIC ATAXIA AND PAEALYSIS 
FROM ANAL DIPHTHERIA— CURE.* 

Mr. B., aged 58 years, has enjoyed good health with exception 
of hemorrhoids. Never any fulgurating pains, or diplopia. 

Nov. 12, 1880, was operated on for large hemorrhoids by 
injection of carbolic acid and oil. Reaction followed, with 
diphtheritic exudation on hemorrhoidal masses, chill, febrile 
movement, and much prostration. The anus was well about 
Thanksgiving (27th). 

Early in December seemed fairly well, but a few days before 
Christmas legs were weak and feet numbish. Gradual increase 
in weakness of legs, and a few days before examination, hands 
became w^eak, awkward, and numbish. Bladder unaffected ; no 
spinal or peripheral pain, or cincture feeling. 

Examined January 25, 1881. Presents paresis of upper and 
lower extremities, with numbness and slight but distinct an- 
aesthesia of feet, legs, and hands. The striking symptom, how- 
ever, is the ataxia, which is typical both in hands and legs ; no 
trace of patellar tendon-reflex. Pupils normal. During the 
ensuing two weeks the paresis increased, and gradually obscured 
the ataxia. 

Feb. 5th. Lies quite helpless on couch, almost no voluntary 
power in arms or legs ; sensory symptoms as above. No atrophy 
or degeneration reaction. Improvement in voluntary power 
began February 15th, and progressed steadily, with correspond- 
ing diminution of the anesthesia. 

* Read before the American Neurological Association, June l?th, 1881. Re- 
printed from the Journal of Nervous and Mental Disease, July, 1881. 



494 DIPTHERITIC ATAXIA AND PARALYSIS. 

March 29th. Walks with a cane. 

May 3d. Is practically cured ; only remains of attack is a 
slight occasional numbness in soles of feet ; no tendon-reflex. 

May 17th. A trace of patellar tendon-reflex on both sides. 

The treatment consisted at first in the use of belladonna and 
ergot ; later nux vomica and iron. At the last a simple solution 
of strychnia in nitro-muriatic acid was given. 

A thorough electrical treatment and massage were also had. 
Until March 16th galvanism was used only ; stabile ascending 
current to limbs and spine. After this date faradism was care- 
fully used on the recovering muscles. The massage was made 
proportionate to the paralysis, and in the last few weeks was 
vigorously done. 

I looked upon the case as one of myelitis, probably infectious, 
with deposits of minute organisms around all the anterior and 
posterior nerve roots entering the spinal cord, probably first in 
the posterior segments of the cord, and the anterior afterward, 
judging from the succession of events. I was much interested 
in the case because of the difficulty of diagnosis. I was 
strengthened in my suspicion of diphtheria from the absence 
of pupillary symptoms and fulgurating pains. 



A SECOND CONTRIBUTION TO THE STUDY OF 
LOCALIZED CEKEBEAL LESIONS.* 

In 1877 I reported to the American Neurological Association t 
a number of cases with accurate post-mortem examinations, 
illustrating the doctrine of localization of functions in the brain. 
Since that time I have made several similar observations, some 
of which have been published as isolated cases. In the past 
year two remarkable cases of cerebral tumor bearing upon the 
Ferrier hypothesis have been added to my records, and I think 
that the time has come to offer a second installment of facts in 
this department of medicine to the medical public. I shall first 
relate my last unpublished cases, and point out their signifi- 
cance, then reproduce in brief the isolated observations, positive 
and negative, which I have separately published. 

I would only claim, in offering this second paper, to be 
adding a few trustworthy data to a mass of observations 
which tend to support the theory of cerebral localization. This 
theory or hypothesis can be established as true only by great 
numbers of pathological facts corroborating the results of ex- 
perimental physiology and of anatomy. 

Case I. — Mrs. I. D., aged 58 years, seen October 3d, 1880. 

A strong, intellectual woman, who has enjoyed good health. In early 
spring was overworked and auxious about the outfit of a daughter who was 
to be married. 

In May began to have a peculiar general headache (different from any she 
had had before), most marked in the occipital region, and always worst at 
night. She often complained of a sore, stiff feeling in the neck on rising in 
the morning. At times, in connection with headache, has had nausea and 
vomiting. This headache has been a prominent symptom ever since, amount- 
ing at times to agony. 

Later in the month of May, or in the early part of June, there was noticed 
a trembling of the left hand ; this increased, and was accompanied by evident 

* Read by title at the seventh annual meeting of the American Neurological 
Association, June 17, 1881. Reprinted from the Journal of Nervous and Mental 
Disease, vol. viii., No. 3, July, 1881. 

f P. 202. 



496 LOCALIZED CEREBRAL LESIONS. 

loss of power. Relatives of the patient describe two sorts of movements of 
the left arm: first, a slight and nearly constant fine tremor; and, second, 
attacks of considerable jerking, so that the patient was obliged to hold the 
affected left hand with the right. Each day there were several such attacks, 
some lasting an hour. 

Has grown steadily worse ; more headache, marked paresis of the left arm, 
with some contracture, slight weakness of the left leg. Sight not so good- as 
formerly, but there has been no diplopia, hemiopia, etc. 

Last night the pain was intense through the mastoid regions, and in the 
whole of the head. Was given .01 sulphate of morphia occasionally, and by 
10 a.m. to-day had taken .05; is semi-comatose, but still groaning from pain; 
the left hand and arm are semi-flexed and stiff. 

Examination at 5 p.m. Patient is profoundly asleep, yet can be roused; 
respiration is slow and very irregular, but not of the Cheyne-Stokes type. 
When spoken to loudly, points (with right hand) to the sides of the head as 
the seat of chief pain; is able to swallow. The pupils are small and fixed, 
the right larger. The right internal rectus is weak. The left lower face is 
paretic. The left arm and hand are strongly adducted and semi-flexed on 
the thorax, and passive extension is difficult and painful. Legs extended, 
not stiff; both show good reflexes at the knees. Left hand and leg are less 
sensitive than the right. The pulse beats about 72 per minute, and is weak ; 
the axillary temperature is 37.4° C. After the use of atropia, I was able to 
observe typical neuro-retinitis (choked disk) in both eyes ; no hemorrhages. 
Urine contains a trace of albumen. 

My diagnosis was tumor in the right cerebral hemisphere, complicated by 
morphia narcosis. I considered that very probably the tumor Avas in the 
median region of the hemisphere, in the so-called centres for the arm and leg, 
according to Ferrier's experiments and to recent post-mortem facts. 

A great many notes were made during the progress of the case, but they 
only show the extraordinary variations in the state of the patient, which I 
and others have observed in cases of cerebral tumor. Some days Mrs. D. 
would be sitting up and very bright, and the next day might appear moribund. 

On October 5th is up on a lounge, is bright and cheerful, though mind 
wanders at times ; headache has returned about the vertex. Can converge 
eyes well. Exhibits common left hemiparcsis, with contracture, most 
marked in arm and hand. Ordered solid food and iodide of potassium. 

October 9th. The left arm is completely relaxed and the tongue is straight. 

October 10th. Growing steadily worse. Attacks of pain in the head, at 
times very severe, controlled by morphia and chloral. The arm is now com- 
pletely paralyzed, with painful contracture of elbow and shoulder. No 
voluntary motion in left arm for forty-eight hours ; the left leg, which four 
days ago could be drawn up fairly well, is now nearly motionless. Left face 
is paretic, but tongue points straight. Answers questions, but wanders ; 
wants to be dressed, to go out, etc. Wets the bed. Optic nerves choked as 
before. 

October 13th. State of paralyzed limbs has varied from partial to complete 
paralysis. Extreme sensibility to narcotics. 

October 15th. Sulphate of quinia produced delirium the other evening, and 



LOCALIZED CEREBRAL LESIONS. 



497 



she is easily plunged into dangerous narcosis by morphia. Morphia .002+ and 
chloral .15 have some effect. 

November 1st. Divergent strabismus and slight drooping of right upper lid. 
Speech very indistinct. Left hemiplegia as above. Delirious and semi- 
comatose at different times. Incontinence of urine and faeces. 

Xovember 4th.. Greater coma and first appearance of fever. 7.30 A.M. 
Pulse, 162; respiration, 52. At 4.30 p.m., pulse, 136; axillary temperature, 
39.2° C. ; breathing moribund, i. e., inspiration and expiration equal. Left 
arm in semi-flexion on chest, elbow and wrist limber, fingers decidedly 
contractured. At 10 p.m., respiration, 56; pulse, 160; axillary temperature 
(six minutes), 39.8° C. Right eye is in slight external strabismus and motion- 
less; the left is in continual lateral motion; pupils medium sized, equal. 

November 5th, 1 a.m. Respiration, 56; pulse. 176; axillary temperature, 
40.15° C. ; jaws firmly closed. Death occurred before daylight, and the 
temperature finally rose to 40.6° C. 

No post-mortem measurements could be made. 

The autopsy was made about ten hours after death by Dr. 
R W. Amidon under my direction. Drs. "W. R. Birdsall and 
C. Adam were also present. 

Yery little blood escaped on removing the calvarium. The 




Fig. 1. 

Lateral view of the right cerebral hemisphere, after Ecker. Shaded spot represents the location 
of the tumor. Superficially it involved only the ascending frontal gyrus. 
32 



498 



LOCALIZED CEREBRAL LESIONS. 



pia mater was found excessively dry and sticky, and without gloss. 
There was a marked prominence of the right parietal portion of 
the brain, causing the whole hemisphere to appear much larger 
than the left. The convolutions about the upper end of the 
fissure of Eolando on the right side were very much flattened. 

A vertical, transverse section passing through the middle of the 
motor zone revealed a consistent, grayish-red tumor, lying chiefly 




Fig. 2. 

Transverse vertical section through the right hemisphere, anterior view ; after photo. No. 5 of 

Bitot. The gray shaded mass in the upper part of the figure represents the tumor. 

in the right ascending frontal convolution, wholly under the pia, 
and in the angle formed by the ascending frontal convolution 
and the paracentral lobule at the top of the brain. See Fig. 1. 

The tumor was about the size of a small English walnut, well 
defined from the brain substance, vascular, and at points almost 
gelatinous in structure. 

The right third nerve was grayish. Eight eye removed, 
showed an elevated papilla. 



LOCALIZED CEREBRAL LESIOXS. 499 

The brain and eye were placed in bichromate of potassium 
solution for hardening. 

The following is a study of the topography of the lesion made 
upon the hardened specimens : 

The tumor, ovoid in shape, lies in the upper part of the 
ascending frontal convolution and in its subjacent white mat- 
ter. It measures upon the vertical transverse section of the 
brain, transversely, 15 mm. at its pia mater attachment, 20 mm. 
in its middle, and vertically, from its deepest point to the pia, 
28 mm. See Fig. 2. 

It extended well across the bottom of the fissure of Rolando, 
so as to slightly impinge upon the ascending parietal gyrus. 
The distance from the surface of the brain in the longitudinal 
fissure to the internal edge of the tumor is 25 mm., thus leav- 
ing the paracentral lobule and its attached white matter intact. 

The tumor is spongy in texture, well defined from the sur- 
rounding cerebral substance, and seems firmly united to the pia. 
The microscope shows it to be an alveolar carcinoma. 

It probably caused a great deal of pressure, in spite of its 
small size. 



Case II. — L. K., an upholsterer, aged 34 year?, came to the Manhattan Eye 
and Ear Hospital, department for Nervous Diseases, October 6, 1879. He was 
a strong and healthy-looking German. The following is a transcript of my 
notes : 

Has had attacks of right-sided epilepsy. First seizure was about two years 
ago (1877), and the attacks have occurred at the rate of one every four or six 
weeks. In the last few months has had attacks every week, and even several 
times a week. The phenomena have always been the same in these numerous 
attacks; the spasms being wholly restricted to the right arm and leg; the 
slightest attacks are only momentary shocks on the right side of the body — 
no spasm in the face. Even in the severe attacks the spasm is wholly clonic, 
and he never loses consciousness. An exception to this occurred on August 
5, 1879, when he had a severe seizure with loss of consciousness. 

The attacks last from a few seconds to a few minutes ; they are preceded 
by a sensation of something rising from below upward to the throat, and 
there causing choking. He never froths at the mouth, or bites tongue, or 
micturates in attacks, and during them he is often able to speak a few words 
in a jerky manner. 

In intervals between attacks has good use of his right hand and leg ; he is 
now working at his trade. Mind clear and calm. 

Very lately has noticed a slight weakness in the right limbs, and the right 
leg has been the seat of an indefinite numbness. Complains of diffused head- 
ache, mostly frontal. Xo vertigo or petit -mal. 



500 LOCALIZED CEREBRAL LESIONS. 

Denies injury to head and any venereal disease. 

Examination. — Manner, appearance and speech normal. No facial palsy ; 
tongue straight ; pupils equal. Right hand grasps 45° and 48°, and the left 
45° and 45° on Mathieu's dynamometer. No anaesthesia to careful testings. 
Patellar tendon-reflex absent on the left side, and strong on the right (never 
sharp pains in legs). The walk is rather of hemiplcgic type on the right side; 
the right foot is held slightly in equino-varus position. Complains of sight of 
right eye, and states that when a soldier he was obliged to aim with the left 
eye. Examination of eyes by Dr. J. O. Tansley shows myopia of right eye, 
but optic nerve normal. 

The diagnosis was a cortical lesion (tumor ?) in the left hemisphere, involving 
the upper part of the motor area. 

The following mixture was ordered: 1^. potassii iodidi, 15.; potassii bro- 
midi, 30. ; aquae, 200. ; S. : one teaspoonful before each meal, and two at 
bedtime, in plenty of water. 

Oct. 10th. No spasm since beginning of the treatment, but the paralytic 
phenomena have increased ; the walk is distinctly hemiplegic on the right 
side. Still works. Ordered to continue treatment, with addition of 4. ext. 
ergotae fid. with the evening dose of bromide. 

Oct. 13th. No attack. Speech normal • tongue deviates slightly to the 
right. 

Oct. 17th. Slight spasm in the right arm yesterday ; increasing paresis. 
Right hand squeezes 44° and 45° ; the left, 50° and 45°. Ordered only three 
teaspoonfuls of bromide mixture at bed-time. To take besides twenty drops 
of a saturated solution of iodide of potassium three times a day in water. 

Nov. 10th. No sj^asm ; paresis of right leg more marked ; walk distinctly 
hemiplegic. 

Nov. 20th. Dr. Amidon was summoned to see the patient at his house. 
Has violent headache, more to the left of the median line at the vertex ; pho- 
tophobia, nausea, and almost constant vomiting. There is complete paralysis 
of the right arm and leg, and these parts are codcmatous. Partial relief by 
hypodermic injection of .02 sulphate of morphia thrice during the day. 

Nov. 22d. The pain has continued intense. Has asked to be killed. No 
aphasia. Eyes, examined by ophthalmoscope, show myopia 3.5 in each eye; 
fundus normal ; sleep induced by rectal injection of chloral. 

Nov. 30th. Headache lias continued intense, requiring chloral and morphia. 
Has also had bromide and iodide of potassium as above. Some motion in 
fingers and right foot (lost on 31st). 

Nov. 14th. Less headache, but continued right hemiplegia. Bed-sore 
beginning over sacrum. Some hesitancy of speech. At no time any aphasic 
defect. 

Nov. 19th. Eyes again examined (without atropine) ; right fundus well 
seen, and found normal. 

Nov. 21st. First signs of paresis in face ; right cheek looks weak, and 
tongue points a little to the right side. Still has very severe headache. 

Nov. 30th. Involuntary escape of urine. Scarcely able to speak from 
difficulty of articulation. At times silly. 



LOCALIZED CEREBRAL LESIONS. 501 

Dec. 4th. Cannot be understood. Some contracture at right elbow, and 
the muscles of right arm and leg show some atrophy. 

Dec. 19th. Paralysis now very marked about right cheek. 

Dec. 31st. Quite a large bed-sore has formed on the right side of the 
sacrum. Marked atrophy of right arm and leg ; elbow very stiff. Is semi- 
comatose. Pupils moderately small. Understands what is said to him, and 
tries to protrude his tongue when asked. Profuse sweating. 

Jan. 2, 1880. Much brighter; speech can be understood. Of late has had 
no treatment except chloral occasionally. 

Jan. 4th. Beginning of terminal stage. Fever and rapid respiration. 
a.m., axillary temperature, 38.8° C. At 5 p.m.. asleep and sweating profusely. 
Pulse, 12G ; respiration, 26 ; temperature, 39.2° C. in axilla ; in the rectum 
the thermometer indicates 40.1° C. 

Jan. 5th. Fever and rapid respiration all night. At 11 a.m., pulse, 126 ; 
respiration, 56 (shallow); rectal temperature, 41.25° C. At 2 p.m., comatose 
without stertor ; skin moist. Eyes in conjugate deviation to the right side ; 
head straight. Pulse, 135; respiration, 50; rectal temperature, 41.6° C. 
At 4 p.m., died. 

The autopsy was made by Drs. K. "W. Amiclon and W. E. Bird- 
sail twenty-four hours after death. The calvarium was found very 
thin ; translucent in spots. Dura mater normal. No subarach- 
noid fluid. There were many large superficial cerebral veins. 
The left motor area gave a sense of fluctuation ; the convolutions 
of this part seemed normal, but were flat. On attempting to 
remove the falx cerebri in the usual manner, it was found ad- 
herent to the inner surface of the left hemisphere, pretty well 
back toward the tentorium. The cortex was ruptured in this 
location, and a gelatinous, bloody mass escaped. The rest of 
the encephalon seemed normal to external inspection. 

A vertical transverse section was made through both hemi- 
spheres in the motor area, passing through the ascending frontal 
gyri. Occupying the centrum ovale underneath the left cortical 
motor area, and completely undermining it, was a large cavity 
capable of holding 100 cc. (?), very much resembling a distended 
lateral ventricle, which contained a large amount of coffee-red 
serum, and also a mass (tumor) lying on its inner side, near the 
paracentral lobule. The tumor was gelatinous and grayish-red. 
The walls of the sac were vascular and grayish, and appeared 
covered by an ependyma-like membrane, which, under the 
microscope, was found to consist of capillaries and portions of 
blood pigment. 

The tumor itself had formed a connection with the falx cerebri 
posteriorly, in the region of the paracentral lobule, and this 



502 LOCALIZED CEREBRAL LESIONS. 

region of the cortex was thinned ; it bulged across the median 
line and indented the opposite hemisphere. 

On the left side the corpus callosum was pressed downward, 
and the optic thalamus was also depressed and flattened. The 
left lateral ventricle was displaced downward and closed by 
pressure ; on opening it, it was found free from disease. These 
appearances were sketched from the fresh surface of section by 
Dr. Amidon, and are shown in Fig 3. 

Sections made through the hardened brain confirmed the 
above notions of the seat of the tumor. It lay wholly beneath 




Transverse vertical section of the brain, Case II, viewed from behind. R, normal right hemisphere; 
i, diseased left hemisphere ; 7, distorted lateral ventricles ; TL depressed corpus callosum ; 
III, thalami optici, depressed on left side ; IV, the tumor ; V, the cavity formed by the 
hemorrhage. 

the externally visible convolutions of the left hemisphere, spring- 
ing from and destroying that part of the first frontal gyrus which 
lies within the longitudinal fissure, above the corpus callosum 
and the paracentral lobule, forcing downward the gyrus forni- 
catus, extending outward into the white substance of the 
hemisphere, causing great compression of the surrounding 
parts, including the upper extremities of the first and second 
frontal gyri, the upper half of the ascending frontal and parietal 
gyri, and, to a less extent, of the upper parietal lobule. 

A part of this pressure was due to the cyst lying outside of 
the tumor, near the convexity convolutions, which is more 
especially shown in the sketch made by Dr. Amidon from the 
fresh specimens. 

The situation and dimensions of the lesion in this second 
case were, therefore, very different from those in the first case. 



LOCALIZED CEREBRAL LESIONS. 503 

In Case H the destructive effects of the tumor were expended 
upon the gray and white substances lying next the longitudinal 




Fig. 4. 
View of inner surface of the left hemisphere, after Schwalbc. Shaded spot indicates the super- 
ficial location of the tumor. 

fissure, and the rest of the hemisphere suffered only compression 
effects. The posterior extremity of the intra-fissural part of 
the first frontal convolution and the paracentral lobule suffered 
the most destructive effects. 

The tumor and cyst were of very irregular shape, and I can 
only give approximate measurements. In the longitudinal fis- 
sure and near it in the brain the tumor was about 60 mm. in 
length (antero-posterior dimensions) ; on a vertical transverse 
section of the hemisphere, as in Fig. 5, it measured 30 mm. 
transversely, and from 30 to 35 mm. vertically. These figures 
include the cyst, which was more developed in the frontal lobe, 
extending forward as far as the posterior part of the second 
frontal gyrus (wholly under it). The other (posterior) extremity 
of the lesion, the solid growth, could be traced, on the median 
surface of the hemisphere, well into the surface of the pre- 
cuneus. 

A microscopical examination of the tumor showed it to be a 
common small-celled sarcoma. 

Remarks. — There are many interesting features in the semei- 
ology of these two cases, but I shall dwell only upon those 



504 



LOCALIZED CEREBRAL LESIONS. 



symptoms which are concerned in the questions of cerebral 
localization. 

In both cases the first motor symptoms were epileptiform, 
and in Case II. the spasm was the first and only symptom for 
many months. In Case I. it was preceded by severe pain in the 




Fig. 5. 
Transverse vertical section of left hemisphere, anterior view ; after photograph No. 4 of Bitot 
Shaded spot in upper part of drawing shows the location of the solid tumor. 

occipital region. In Case I. attacks of jerking of the left arm, as 
well as trembling of that member, were observed by the patient 
some weeks before the weakness became apparent. There was 
no jerking of the cheek or leg. It was a brachial monospasm. 
It is remarkable and most instructive to note how quickly pare- 
sis and paralysis followed, these phenomena being for a long 
time limited to the arm ; a brachial monoplegia succeeding the 
brachial monospasm. Contracture of the arm and hand also 
showed itself, but at what time is not definitely stated. 

Late in the disease, when she came under observation, the 
left lower face and left third nerve were somewhat paretic, the 
sensibility was somewhat impaired on the left side of the body. 



LOCALIZED CEREBRAL LESIONS. 505 

If it be permissible to formulate the chief symptoms observed 
during life in correlation with the lesion found post mortem, then 
this (Case I.) was a remarkable instance of irritating and destruct- 
ive lesion of the upper part of the right ascending frontal gyrus, 
causing brachial monospasm and brachial monoplegia on the 
left side (with other phenomena of secondary logical value). 

In Case II. the course of the motor phenomena was quite dif- 
ferent. There was a period of two years, previous to the patient 
being seen by me, in which the only symptom was right hemi- 
epilepsy. That is to say, from time to time clonic, epileptoid 
spasms occurred in the right arm and leg for a few moments. 
The face was never affected, the patient could usually talk in the 
paroxysm, and he only once lost his consciousness. He was 
unable to say whether the spasm appeared first in the arm or 
in the leg. 

At the time when the patient presented himself at the hospital 
the paralytic phenomena were just developing. He was still 
working all day at his trade, and was not conscious of the partial 
hemiplegia. This was, and remained until the apoplectic attack, 
more marked in the lower than in the upper extremity. At the 
time of first examination the right hand (affected side) was still 
stronger than the left hand, but the walk was slightly hemi- 
plegic, the right foot being held in a slight equino-varus posi- 
tion. There was then no facial paresis and no aphasia. 

Later the epileptiform attacks were controlled by bromide of 
potassium, but the hemiplegia progressed, still greater paresis 
being noted in the lower extremity. 

About six weeks after first calling at the hospital, the patient 
was stricken down by an apoplectic attack, which rendered the 
right hemiplegia complete in the arm and leg, with marked 
paresis of cheek, but never aphasia. This attack obscured the 
symptoms which we may reasonably assume had been caused by 
the tumor. At no time was there marked anaesthesia on the 
paralyzed side. 

Headache was remarkably slight prior to the occurrence of 
the apoplectic attack. 

The post-mortem findings explain all these symptoms very well, 
I think. The cyst outside of the tumor proper, found in the 
white substance of the hemisphere, was the remains of a hemor- 
rhage which took place at the moment of the apoplectic attack, 
which was characterized by intense pain in the head, vomiting, 



506 LOCALIZED CEREBRAL LESIONS. 

collapse, and complete right hemiplegia. Dr. Amidon states 
that in removing the brain a small laceration occurred, and " a 
gelatinous bloody mass escaped," probably the contents of the 
cyst, about seven weeks old. 

The long stage of hemi-epilepsy without paresis, two years, is 
accounted for by the fact that the morbid growth began upon 
the median surface of the hemisphere, springing from the pia 
covering the inner winding of the first frontal gyrus, and per- 
haps the paracentral lobule ; at any rate, for a long time it was 
an irritating lesion causing discharges, and only gradually exer- 
cised enough pressure to destroy the irritability of the neighbor- 
ing gyri. The parts of the hemisphere which must have suffered 
first in a destructive manner were the paracentral lobule and ad- 
jacent parts (posterior extremity of first frontal gyrus on median 
surface), and in connection with this should be noted the fact 
that paresis of the leg preceded and preponderated over that of 
the arm, until the apoplectic attack occurred. The absence of 
aphasia throughout, and of facial paresis previous to the hemor- 
rhage, are likewise of interest. 

If I may venture to formulate this case, I should define it as 
one of irritating ana* destructive lesion of the left paracentral 
lobule (and adjacent parts), causing crural and brachial mono- 
spasm and monoplegia, with greater development of symptoms 
in the leg. 

It will be seen by a reference to the now numerous recorded 
cases of localized cerebral lesions that the two cases which I 
report are in sufficient harmony with the results reached by 
many observers thus far, viz., that the " centres " for the hand 
and arm are in or about the ascending frontal gyrus in its mid- 
dle region, while the "centres" for movements of the lower 
extremity are further backward in the posterior extremity of the 
ascending frontal and ascending parietal gyri, and their pro- 
longation upon the median surface of the hemisphere, known as 
the paracentral lobule. 

The many other interesting features of these two cases of cere- 
bral tumor, I purpose considering in a future article upon the 
semeiology of cerebral tumors in general. 

Before closing this contribution, it may perhaps be well if I 
present a brief resume of the other cases of localized cerebral 
lesion which I have thoroughly studied (t. e., while alive and 
2')ost mortem) since the publication of my first paper on localiza- 



LOCALIZED CEREBRAL LESIONS. 



507 



tion. Most of these cases have been published in medical 
journals. 

Case III. — Hemiplegia with first symptoms in foot, and a limited cortical 
lesion. 

In November, 1878, I saw, in consultation with Dr. Granniss, of Say brook, 
Ct., a gentleman aged 54 years, who was hemiplegic on the left side, and 
almost unconscious. The following account of his illness was furnished : 

In December, 1877, after having enjoyed good health, he awoke one night 
with clonic convulsions of the left toes, foot and leg only. There was no 
impairment of consciousness, no spasm in any other part. He watched the 
spasm some time, and made comments on it. Since, there has gradually de- 
veloped a left-sided hemiplegia. For months only the foot and leg were pare- 
tic ; in the last few weeks the left arm has become weak, and now the left 
cheek is paretic, though the relatives have not noticed it. In January, 1878, 
vision became impaired, but an examination by Dr. Noyes revealed no cause. 
In the last few weeks patient has seen double at times, and sight has gradually 
failed. Severe headache has existed from the first ; frontal, bilateral pain, 
most marked on the right side. The pain has been worst about daylight. In 
the past month pain decidedly nocturnal. On a number of occasions' "lost 
himself" while out of doors, not remembering where he had been (petit-mal ?). 
A business associate thinks that patient has committed errors in judgment. 
No extravagance in design or in deed. Lately has become stupid and semi- 
comatose. 

Since January, 1878, a tumor-like swelling has appeared over the right 
parietal region. No albuminuria, but h&s had several attacks of gout. After 
severe cross-examination, patient admits having had a chancre fifteen years 
ago, treated with mercury ; denies secondary and tertiary symptoms. 




Lateral view of right cerebral hemisphere, with lesion. 



Examination showed a typical left hemiplegia, face and limbs. No diplo- 
pia, pupils small and equal ; after atropia there is found a well-marked doub- 
le neuro-retinitis. Sensibility preserved on the paralyzed side. Articulation 



508 LOCALIZED CEREBRAL LESIONS. 

indistinct, no aphasia. Stupor is peculiar, like that of drunken sleep. Pa- 
tient can be roused by loud talking and shaking, and then answers correctly 
(showing fair memory) and clearly. The swelling upon the head, raised per- 
haps 1.5 cm., is just above the right parietal eminence, extending inward 
to the median line, and forward almost to the vertical line from the meatus 
auditorius to the bregma. This tumor overlies Ferrier's centres for the leg. 

Diagnosis : External and internal nodes involving dura mater and the sub- 
jacent gyri of the right hemisphere. 

A few days later the patient died comatose, and after much trouble Dr. 
Granniss secured a partial autopsy. He was not allowed to raise the brain 
from the skull or to incise it. He simply removed the calvarium and noted 
the lesions at the vertex. He found that there was an internal as well as an 
external osteitis, forming quite a. tumor, which had, after adheriug to the 
dura, exerted great pressure upon the subjacent convolutions of the right 
hemisphere. Dr. Granniss marked the location of the Cortical lesion upon an 
Ecker's diagram, and the annexed wood-cut is a copy of his sketch. 

It is of course very much to be regretted that a thorough examination of 
the brain was not permitted, but in view of numerous recent cases, it is im- 
possible not to admit a causal relation between the lesion causing pressure 
upon the inner end of the right ascending frontal and parietal convolutions 
and the symptoms in the left foot and leg — spasm and paralysis.* 

Case IV. — Aphasia with word-deafness ; no permanent paralysis ; lesion in 
the parietal region, f 

The main facts of the last illness of the late Dr. C. M. A., of New York, 
are already well known to his numerous friends in the medical profession, 
who watched the progress of his disease with painful interest. Throughout 
his illness he was attended by his partner, Dr. A. Dubois, and myself. He 
was also seen in consultation by Profs. Austin Flint, Sr., John T. Metcalfe, 
H. D. Noyes, and Dr. Allan McLane Hamilton, and for several months was 
under the professional care of Prof. E. C. Seguin. 

Dr. A. was born in 1827, and was therefore fifty-two years of age at the 
time of his aphasic attack. At the age of eleven years he had a long illness, 
which was called " brain fever." Whatever may have been its real nature the 
illness was sufficiently severe to seriously endanger life, and for several years 
retarded his growth. At about the age of thirty years he had an attack of 
inflammatory rheumatism affecting the larger joints. This was followed by 
three or four other attacks within the next few years, but none of them lasted 
longer than from three days to a week, or was attended, so far as we can 
learn, by any cardiac complication. Twelve years ago he had a well-marked 
attack of gout, and since then had three or four other paroxysms, the most 
severe one five years ago, after a violent quinzy, when both great toes were 

* Archives of Medicine, vol. if., p. 105. (A remarkable case of hemorrhage 
under the paracentral lobe, with paralysis of the opposite leg, is recorded by Dr. 
Miles, of Baltimore, in the same journal, p. 103.) 

t Dr. A. B. Ball. A contribution to the study of aphasia, etc. Archives of 
Medicine, vol. v., No. 2, April, 1881, p. 136. Inserted here with the permission 
of Dr. Ball.— [R.W.A.] 



LOCALIZED CEREBRAL LESIONS. 509 

affected. For several years before his aphasic attack, he was subject to flatu- 
lent dyspepsia, and had occasional outbreaks of eczema. It should be noted 
here that neither gout nor rheumatism was hereditary in his family, and that 
the most frequent cause of gout — over-indulgence at the table — was notably 
absent in his case, as he was usually very abstemious both in eating and drink- 
ing. In November, 1877, he had a severe attack of renal colic. The con- 
cretion was arrested in the ureter, and not discharged until the end of ten 
days, after repeated jwoxysms of colic. The stone, on analysis, was found 
to be composed of uric acid. On February 1, 1878, he attended a concert 
in evening dress, and on his way home became thoroughly chilled. During 
the night he Was awakened by pain and oppression in the chest, these 
symptoms continuing during the following day. As there was no evidence 
of pulmonary lesion, but merely tenderness over the middle portions of the 
chest anteriorly, on both sides, with pain in these situations on movement of 
the pectoral muscles, the symptoms were referred to muscular rheumatism. 
Within a few days he was able to return to business, but was still so far from 
well that some more serious disturbance was apprehended by his medical 
attendants. 

On February 11th, the date of his aphasic attack, he was in much better 
spirits. At half-past eight in the evening he was seen in his office writing a 
letter. A few minutes before ten o'clock he rang his bell violently, and was 
found by his servant lying on the lounge talking unintelligibly. I saw him 
not more than five minutes afterward. He was conscious, but unable to 
answer questions except by a confused muttering. The face was slightly 
flushed; pulse soft, easily compressible, about 90 per minute; the first cardiac 
sound feeble, and no murmur audible. Incomplete right hemiplegia and 
right hemi-ansesthesia. Was apparently aware of the nature of his attack, as 
he pointed to his right arm and left frontal region. By gestures he finally 
succeeded in directing my attention to important cases in his note-book, 
requiring attention on the following day. At 11 o'clock he was seen by his 
partner, Dr. Dubois, and with slight assistance walked up two flights of stairs 
to his bedroom. On the following morning he complained of paroxysms of 
pain in the left frontal region. This symptom, which yielded to local applica- 
tions of hot water, annoyed him frequently for several weeks, and recurred at 
intervals during the whole course of his illness. Repeated examinations of 
the heart failed to disclose any morbid condition except feeble action and 
moderate hypertrophy. No albumen or casts in the urine. Absence of fever, 
except on the evening of the third day, when there was a slight rise of tem- 
perature which lasted only a few hours. From this time his physical Condi- 
tion steadily improved, and by the end of six weeks his general health was 
fairly restored. Beyond slight paresis of motility and sensation on the right 
side the only marked change was the aphasic condition to be presently 
described. During the summer and autumn of 1879 his physical condition 
remained fairly good. The kidneys performed their w r ork well, although it 
was evident from the occasional appearance of traces of albumen and casts in 
the urine, and from the enlargement of the left ventricle without valvular 
murmurs, that the kidneys had probably undergone cirrhotic changes. At 
no time was any increased arterial tension noticed in the sphygmographic 



510 LOCALIZED CEREBRAL LESIONS. 

tracings, but this absence was ascribed to muscular degeneration of the 
cardiac muscle, as feeble action of the heart was a constant symptom through- 
out his illness. 

In March, 1880, he had another attack, which was supposed to be due to a 
small cerebral hemorrhage. At dinner, while talking with a friend, he sud- 
denly turned his head to the right, and began muttering incoherently. With 
assistance, he immediately left the apartment and walked to his bedroom, 
muttering all the way with his head turned f;o the right. At my visit, half 
an hour later, when his consciousness was fully restored, he said that the 
attack began with an explosive noise in the head like a pistol-shot. Imme- 
diately he heard some one talking to him over his right shoulder, and 
turned to see who was addressing him. 

Every word uttered by himself, he said, was mockingly repeated by this 
imaginary individual, and the mutterings his friends had heard were his 
indignant protests against the insult. On examination there was found slight 
paralysis, with numbness and anaesthesia on the left side. These symptoms 
disappeared after a few days, his mental condition remaining without appar- 
ent change. Shortly after this attack it was evident that his heart was failing 
in power. He frequently complained of breathlessness on exertion, and the 
heart sounds were feeble, with occasional intermittence of beat. Toward the 
end of May he was seized with what proved to be his final attack. The 
symptoms were slight fever for several days ; oppression in the chest, with 
shortness of breath ; slight cough, generally dry but occasionally accompanied 
by expectoration tinged with blood ; and marked tenderness over the region 
of the heart. At a few examinations a faint aortic obstructive murmur was 
heard, or rather a soft blowing sound over the base of the heart near the aortic 
valves, with the first sound. Urine nearly normal in amount; specific gravity 
varying from 1,012 to 1,018; no albumen, and no casts except a few hyaline 
cylinders found at one examination. These symptoms were hardly sufficient 
to warrant a positive diagnosis, but they seemed to point to endocarditis with 
possibly myocarditis, and this view was confirmed, or at least considered 
plausible, by Prof. J. T. Metcalfe, who saw him in consultation. The urgent 
symptoms subsided by the end of a week, but he was still much prostrated, 
and complained of giddiness and mental confusion. On one occasion he 
exhibited in a marked form the so-called rotatory phenomenon, turning over 
rapidly to the right, and would have rolled out of bed had he not been pre- 
vented. On June 19th, about 3 p.m., he suddenly became totally blind. Dr. 
Dubois, who saw him shortly afterward, found him still partially blind, but 
gradually regaining his vision. At my visit, two hours later, he was per- 
fectly conscious, with his sight fully restored. Half an hour afterward he 
fell into a quiet slumber, from which he suddenly awakened at 7 o'clock, 
exclaimed " Oh! " and died instantly. 

In considering the aphasic symptoms which constituted the 
most striking and interesting feature of his case, a few prelimi- 
nary remarks on the essential nature of aphasia maybe permitted 
before analyzing the symptoms in detail. 



LOCALIZED CEREBRAL LESIONS. 511 

The interchange of thought between members of the human 
family is carried on by means of various symbols, that is, by 
signs which stand for the ideas they represent ; for example : 
articulate sounds, written language, gestures, facial expression, 
mathematical, musical, and other signs. In aphasia this sym- 
bolic function, or capacity to interpret and express thought in a 
symbolic form — the facultas signatrix of Kant — is more, or less 
seriously impaired. In some cases the chief difficulty is in the 
direction of symbol expression (ataxic aphasia), the concept being 
present, but failing to enunciate itself on account of some lesion 
in the motor tract concerned in the expression of symbols. In 
other instances the concept is present in the mind, but the ap- 
propriate symbol for it is forgotten (amnesic aphasia). In a 
third class of cases there is also a defect in the capacity for com- 
prehending symbols. Certain auditory and visual impressions, 
especially those of word symbols, fail to recall into conscious- 
ness their corresponding concepts, although the capacity for 
forming such concepts under the influence of other stimuli may 
still be retained. When concepts can no longer be formed, the 
lesion involves the fundamental processes of thought, and 
extends beyond the sphere of simple aphasia. The latter term 
fails, however, to recognize the impaired capacity to understand 
symbols, and as most cases of aphasia present some degree of 
this derangement, Finkelburg * has proposed to substitute the 
word " asymbolia" as a generic term for all the phenomena of 
aphasia. Kussmaul t prefers the term asemia, suggested by 
Hteinthal, as being still more comprehensive ; " symbol " rep- 
resents an idea behind it, whereas " sign " often represents 
merely an emotion. In the following description of the aphasic 
symptoms in Dr. A.'s case, we shall use the word "symbol" in 
preference to "sign," as there was no difficulty in comprehend- 
ing or expressing emotions. Our classification is based upon 
that of Spamer. J 

I. — EXPEESSION OF SYMBOLS. 

a. Disturbances of speech. — On the morning following the first 
paralytic seizure, by which time the general shock to the brain 
had abated, it was evident that the cerebral disturbance was 

* Berl Klin. Wochenschrift, 1870, band vii., p. 449, 460. 

f Ziemssen's Cyclopaedia of Medicine, American edition, vol. xiv., p. 609. 

% C. Spamer. Archiv fur Fsychiatrie, band vi., p. 526. 



512 LOCALIZED CEBEBBAL LESIONS. 

limited chiefly to the verhal expression of ideas. His general 
intelligence was fairly well preserved, and lie understood much 
that was said to him, but there was a marked defect in 
verbal expression. His principal difficulty was with proper 
names and common nouns. When a glass of milk was held 
before him, he said : " That is something to drink," recognizing 
at once its several attributes, its color, uses, etc., but the 
word which combined these qualities into a single concrete ex- 
pression, or symbol, he could not utter, even when the word 
was repeated to him. He had less difficulty with adjectives, 
verbs, and adverbs, that is, with words of less concrete symbolic 
character. His vocabulary of proper and common nouns very 
soon began to increase. "Within the first few days we succeeded 
in teaching him a number of such words by directing his atten- 
tion to the movements of the lips and tongue in pronunciation. 
My own name, being short and easily pronounced, he learned in 
one day, and rarely afterward forgot it. Long names of indi- 
viduals, or long words which he rarely had occasion to use, he 
seldom mastered completely at any period of his rllness. Dur- 
ing the summer and autumn of 1879 his vocabulary increased 
so as to include a considerable number of words used in ordinary 
conversation. With these he generally succeeded in express- 
ing his ideas fairly well, but an attempt to leave the beaten track 
resulted in mental confusion and inability to proceed with the 
conversation. In rare instances his conversational powers 
astonished his friends, and gave him delusive hopes of ultimate 
recovery. On one occasion he conversed with fluency on various 
topics for nearly an hour, with a friend who had not met him 
for several years and was unaware of his illness. His friend 
noticed no aphasic disturbance during the interview, and was 
greatly surprised afterward on learning the facts of the case. 
Such flashes were, however, only intermittent, and it became 
more and more evident that anything like perfect recovery was 
hopeless. 

In conversation, true paraphasia, that is, the substitution of 
wrong words, was rarely noticed. Almost invariably the word 
uttered bore some resemblance to the correct one, and differed 
from it in only some of its letters. Thus the first letters were 
usually correct. This fact was of great assistance to him in 
conversation, as it enabled him, when he knew the first letter, to 
find the correct word in a dictionary or work of reference, where 



LOCALIZED CEREBRAL LESIONS. 513 

he at once recognized it as soon as he saw it, showing that the con- 
cept was present in his mind in a latent form, and needed only 
the right stimulus to recall it into consciousness. His Medical 
Register was frequently consulted for physicians' names he was 
unable to pronounce, as he retained, to a marked degree, his 
interest in news affecting the medical profession. 

In the expression of musical and other non-verbal sounds, as 
in singing, whistling, and imitation of various significant sounds, 
there was no observable deficiency. 

As regards the alphabet and numerals the same cannot be said. 
At the outset of his illness he was able to pronounce only a few 
letters, and could not count above four. With training, however, 
he in time learned most of the alphabet, but never succeeded in 
spelling any but short and simple words. Counting he reac- 
quired quite perfectly, and was able to solve simple sums in 
arithmetic, that is, to express their answers verbally. Even 
when unable to do this he could often write the answers correctly. 
When both these efforts failed him he was frequently able to 
recognize the correct answers if shown to him in writing. 
During the latter part of his illness he supervised his business 
accounts, and rarely failed to notice mistakes in them made by 
others. This circumstance belongs, however, rather under the 
head of symbol-comprehension than under that of symhol-cxpres- 
sion. 

b. Defects in writing. — At the outset of his illness there was 
complete agraphia. When asked to write the word " cat," he 
took the pencil in his left hand, and drew three perpendicular 
lines, naming them one, two, three. As we shall see in a later 
illustration, this substitution of numerals for letters and words 
was at first very noticeable. He knew the number of letters re- 
quired for the word " cat," but there was no attempt at the forma- 
tion of letter symbols, although he was perfectly aware that his 
straight lines were not letters. Under training he gradually 
learned to form letters with his righ't hand, and after several 
months could copy simple sentences correctly, sign his name in 
his usual clear and elegant handwriting, and even write short 
sentences of his own composition, but more than this he never 
succeeded in accomplishing. 

c. Gesture language. — The capacity for expressing ideas by 
gestures seemed to be unimpaired. He retained much of his 
natural vivacity of manner, more in fact than could have been 

33 



514 LOCALIZED CEREBRAL LESIONS. 

expected in a person of his keen sensibility, when he found him- 
self cut off from the ordinary modes of social intercourse. His 
gesture language had always been a prominent characteristic, 
and now became an important aid in the expression of ideas. 
Names of individuals and objects, which he was unable to re- 
member or to pronounce, he frequently succeeded in recalling to 
others by gestural description, and this was very noticeable even 
early in his aphasic attack. 

II. COMPEEHENSION OF SYMBOLS. 

Before entering upon this branch of our subject it should be 
noted that the senses of sight and hearing in the present case 
were perfect, so far as could be determined by the usual tests. 
With respect to vision, the only exceptions to this statement 
were a transient attack of total blindness a few hours before 
death, and occasional attacks of hemiopia. Prof. H. D. Noyes, 
who made an ophthalmoscopic examination of his eyes in the 
autumn of 1879, reports that " he found no remarkable change 
in the optic nerves or retinae. The arteries of the nerves were 
rather small, and, with this exception, nothing abnormal was 
noted." 

A. — Compreliension of Auditory Symbols. 

a. Spoken words. — Early in his illness, on my remarking to 
him one day, "Dr. Peters called to see you," he replied, "I 
don't know him." The name was repeated several times, but he 
failed to recognize it, although it was the name of an intimate 
friend. The written name was then shown him. " What a fool 
I am," he exclaimed ; "of course I know him." This was the 
first instance in which my attention was drawn to the fact that 
certain auditory impressions failed to be converted into concepts, 
although the conceptive faculty remained intact. Not long after- 
ward he noticed this peculiarity himself, as was shown by his 
remarking to me : " The words I can't pronounce are the words 
I can't hear.'" This observation, the general correctness of which 
was verified by repeated experiments, points to a very interest- 
ing peculiarity in his case. The words over which he stumbled 
in conversation were words which made no intelligible impression 
on his mind when repeated to him, and, conversely, the words 
he failed to understand in conversation were words he had great 



LOCALIZED CEREBRAL LESIONS. 515 

difficulty in pronouncing spontaneously. The concepts represented 
by these word symbols we were generally able to recall to his 
consciousness by other means, such as writing, gestures, etc., 
but even then he was unable to express them, except after a 
certain amount of training. This " word-deafness," except when 
it was possible to stimulate the conceptual centres by visual or 
other impressions, made it extremely difficult to determine how 
much of his aphasia was due to the ataxic and how much to the 
amnesic element. 

b. Musical and other sounds. — His appreciation of music was. 
fortunately well preserved, and was a source of much pleasure 
to him. In attending concerts and operas he exhibited his usual 
good critical taste. The significance of other sounds, such as 
the tone of a bell, the striking of a clock, etc., was perfectly 
understood. 

B. — Comprehension of Visual Symbols. 

On the third day of his aphasic attack a scroll of Scripture 
texts was held before him, and he was asked to read the follow- 
ing sentence : " We love Him because He first loved us. While 
we were yet sinners Christ died for us." He read aloud as 
follows : " We he have two three that I have to have the same. 
I have two three." The substitution of numerals for words is 
here again noticed, as in a previous illustration. The words 
"the same " probably refer to the repetition of "love " in the 
first sentence. He was aware that this rendering of the text was 
incorrect; in fact he almost always knew when he read aloud 
incorrectly, and expressed impatience thereat. Later in his 
illness, when he was able to read sufficiently well to gather from 
the newspaper the main points of news, he remarked to me that 
there were always words in every long sentence which conveyed 
no impression to his mind, and that he was compelled to form 
his idea of the meaning of such a sentence from the other words 
whose meaning he understood. The significance of many of 
these uncomprehended words could be conveyed to him in other 
ways, showing that his failure to recognize the written symbols 
was not always due to a defect in the conceptual centre, but 
rather to a lesion in the channel of transmission from the optical 
centre for word symbols to the ideational centres. 

The same difficulty extended at first also to the comprehension 
of written numerals and their combinations, but, as we have already 



516 LOCALIZED CEREBRAL LESIONS. 

seen, he reacquired, to a certain extent, this capacity under 
training. Gesture language he understood perfectly from the 
start. 

The degree of impairment in intelligence, otherwise than in 
the comprehension and expression of symbols, it was extremely 
difficult to determine, for reasons already given. His intimate 
friends were satisfied that there was much less general mental 
deterioration than those who met him casually would infer. His 
memory of incidents in his own life, of the past illness of his 
patients, and of numerous other details, was strictly accurate, so 
that we could rely upon his statements upon such points in every 
particular. In business matters he always manifested his usual 
tact and good judgment. During the last few months of his life 
he was a constant attendant at the surgical operations of the 
New York Hospital, of which he was an attending surgeon, and 
his criticisms showed that he retained not merely a general 
interest, but also his special knowledge in surgery. On several 
occasions he assisted me in minor surgical operations and dress- 
ings, with his usual deftness and attention to details. At whist, 
euchre, and all games with which he had been familiar, he was 
as expert as ever. During the winter of 1879-80 he consulted 
numerous medical works on the subject of aphasia. Since his 
death I have seen a sheet of paper containing his notes of refer- 
ence to articles on this subject in English and French works 
and journals. The titles, dates, etc., are strictly correct, and are 
written in his usual clear and elegant handwriting. His memory 
of location was particularly well preserved. He could always 
turn without hesitation to the right place in books he wished to 
consult, remembered the houses of friends — that is, their relative 
positions in this city, — and in numerous other ways showed 
that he perfectly understood the spatial relations of objects. 
The only exception to this fact was a singular symptom which 
annoyed him for several months, viz.: a tendency to reverse the 
natural position of objects which he handled, such as table- 
knives, spoons, pencils, canes, etc. He immediately recognized 
his mistake, however, and corrected it, but always spoke of the 
inclination as irresistible. 

As an aid to the interpretation of the aphasic symptoms in the 
present case, we reproduce, below, Spamer's diagram, represent- 
ing the several tracts between the reception of impressions, the 
comprehension of these impressions, and their expression. 



LOCALIZED CEREBRAL LESIONS. 



517 



WRITING WORDS 



cesruaz 



£AR EYE 




Fig. 7. 

The circle in the middle of the diagram, V, represents the ideational tracts. From the right the 

excitations of the sensory nerves pass into the brain. 
n. «.=auditory nerve, n. o.=optic nerve. 
P and i* represents the places where the auditor)- (K) and the optical (G) impressions arc 

perceived. When the impressions reach these points we have merely sense-perceptions 

without associated conceptions. The association with definite corresponding conceptions 

takes place only when the excitation travels onward to B, the conception. From this point. 

the excitation may proceed to C, C, C", the centres of co-ordination for movements in speech, 

writing and gestures. 
JV, N' and N" are the motor nerves concerned in symbol expression (speech, writing, gestures). 

At their termination these nerves are broken up into fibres distributed to individual muscles. 
The diagram represents the reception and tracts of tocret symbols through the eye and ear. The 

tracts of other auditory and ocular impressions are not designated. 

It will be noticed in the above diagram that the tract from P 
to B is represented by a straight line, while the tract from P to B 
pursues a circuitous route. By this distinction Spamer attempts 
a rough explanation of the difference observed in most cases of 
aphasia between the comprehension of auditory word symbols 
and the comprehension of visual word symbols. Cases of marked 
word-deafness, without ordinary deafness, seem to be extremely 
rare ; at least there are very few instances of this kind on record. 
The tract for all auditory impressions, he supposes, lies in close 
connection, and may be represented by a single straight line. 
With visual impressions the case is different. Aphasic patients 
very generally recognize material objects, but exhibit a marked 
defect in understanding written and printed words, as well as 
in expressing the concepts in speech and writing. The tract for 
visual word symbols is, therefore, more or less widely separated 
from the tract for other visual impressions, and lies in some 



518 LOCALIZED CEREBRAL LESIONS. 

parts of its course near the centres of co-ordination for speech 
and writing, or near the tract from B to the latter. This expla- 
nation is ingenious, but hardly satisfactory. If the tract from 
P to B should be represented by .a circuitous route, that from 
P to B could scarcely have been direct in Dr. A.'s case, because 
the word-deafness was even more marked than the word- 
blindness, although both auditory and visual impressions, with 
the exception of word symbols, were interpreted with equal 
acuteness. Indeed, our main reliance, when the word symbol 
failed to be recognized by him in conversation, was to present 
the word to him in writing. The reverse process, that is, the 
presentation of the auditory, in place of the visual, word symbol 
rarely succeeded. In other words, he seldom understood the 
spoken words when he failed to comprehend the written form. 

DR. SEGUIN'S REPORT OF THE AUTOPSY. 

The autopsy was made twenty hours after death, on June 20th. 
The body was well preserved in ice. 

Head. — The dura mater is abnormally adherent to the calva- 
rium, on both sides equally ; no thickening of dura. Pacchio- 
nian bodies small. Marked subarachnoid effusion, which has 
gravitated to posterior regions. Dura of base normal. The 
basilar artery is really a continuation of the right vertebral 
artery; the left being only 1mm. thick. The right vertebral 
and the basilar arteries are the seat of patches of arteritis, 
separated by regions of healthy tissue, but nowhere obstructing 
the flow of blood. Circle of Willis is complete and patent. The 
carotids, just below the circle of Willis, are extraordinarily 
thickened, quite rigid, but not calcareous ; their wall is nearly 
1 mm. thick. The same alterations in patches can be traced in 
the accessible branches of the middle cerebral arteries ; the 
anterior cerebrals are only slightly affected. Nerves at the base 
normal. The left hemisphere is the seat of a large depression 
caused by the destruction of several convolutions, viz. : the 
whole of the inferior parietal lobule, with the first tier of tem- 
poral gyri. The posterior extremity of the angular gyrus, and 
the whole of the ascending parietal, are preserved. This lesion 
is a yellow patch lying in the region supplied by the terminal 
branches of the left middle cerebral artery. To external 
examination, the remaining convolutions are normal, more espe- 
cially the third frontal, the ascending frontal, and the anterior 



LOCALIZED CEREBBAL LESIONS. 



519 



gyri of the island of Reil. The first branch of the middle 
cerebral artery on the left side is pervious, though there are a 
few patches of arteritis near its origin. The main trunk of the 




Fig. 8.— Lateral view of left cerebral hemisphere, after Henle. Shaded spot shows the superficial 
location of the yellow patch. 

artery, in the fissure of Sylvius, and its two terminal branches 
are pervious to the confines of the patch, and in the pia cover- 
ing the patch. The patch was probably caused by blockade of 




Fig. 9.— Diagram of transverse vertical section through left hemisphere, showing the extension 
inward of the patch. This view corresponds to section No. 4, described in the text. 



520 LOCALIZED CEREBRAL LESIONS. " 

smaller arteries which cannot be traced. The right hemisphere 
presents a healthy surface. On opening the fissure of Sylvius, 
the middle cerebral artery is found patent, but bearing a few 
patches of thickening. 

The brain is sliced in transverse vertical sections. 

Section No. 1, about 37 mm. from apex of frontal lobes, pre- 
sents no lesion. 

Section No. 2, at a distance of 25 mm. behind No. 1, passing 
through the posterior extremity of the third frontal convolution 
and cutting off the apex of the temporal lobe, is free from lesion. 

Numerous fine slices made in the speech tract in this region (left 
side) reveal no alterations of structure. 

Section No. 3, 25 mm. further back, showing the lenticular 
ganglion and the thalamus, no lesion. 

Section No. 4, made at 25 mm. behind No. 3, passing through 
the anterior limit 'of the yellow patch above described, and cut- 
ting through the posterior extremity of the thalami. There is 
no lesion to be seen except the yellow patch in the left hemi- 
sphere, and its full extent is well shown ; besides destroying the 
convolutions it extends deep into the white substance of the 
hemisphere to the roof of the lateral ventricle. 

Section No. 5, made at a distance of 25 mm. posterior to No. 4, 
reveals the penetration of the yellow patch as just described. 

Section No. 6 shows no lesion. 

The brain was afterward finely sliced up without any other 
lesion being discovered. 

Sections made at different points in the pons "Varolii and me- 
dulla oblongata seem normal. 

Cerebellum normal. 

CONCLUDING OBSERVATIONS BY DR. SEGUIN. 

Dr. A.'s paresthesia and perversions of muscular sense were 
very curious. He referred his sensations of numbness on the 
right side to homologous regions in the hand and foot, viz. : the 
distribution of the ulnar nerve and that of the musculo-cutane- 
ous in the leg and foot. In the right side, generally, the pares- 
thesias were of drawing up, or tightening, and as if a strong 
rotatory movement were going on in each limb around its lon- 
gitudinal axis, the hand in pronation, the foot in inversion. The 
patient's account of these subjective movements never varied, 



LOCALIZED CEREBRAL LESIONS. 521 

and lie would often illustrate them by moving his hand and fore- 
arm in extreme pronation and rotation. 

The impairment of muscular sense of which he complained 
was something which I had never met with before. If he did 
not use his eyes in prehending objects with his right hand, he 
would find that he had seized them by the wrong end. He 
sometimes found himself standing with the head of his cane on 
the ground and its point in his hand. Frequently, in my pres- 
ence, he essayed to grasp a pen or pencil with his head turned 
away, and repeatedly he found himself holding the object by 
the wrong end, and this after turning it over three or four times 
to get its outlines. 

Yet with these perversions of sensibility there was no com- 
mon anaesthesia, either to pricking, to cold, or to sesthesiometer 
points. 

Dr. A.'s aphasia was complex, but the striking feature in it, 
during my six months' observation, was the word-deafness. 

He could express himself fairly well in short sentences, and 
might for a little while carry on a commonplace conversation 
with a non-expert without betraying his defect ; but he fre- 
quently failed to find the right word, and often found it only 
after struggling a good deal. 

In attempting to speak he would often, after failing to get the 
proper noun, use a corresponding verb or employ synonyms, 
showing that his idea or concept was always correct, but that 
his vocabulary was faulty. He could copy written or printed 
characters quite readily, but experienced great difficulty in 
writing spontaneously. 

All the auditory relations of language were much impaired. 
He used to say that going to church and listening to a sermon 
was to him all a mixed-up, meaningless jargon, like " drub-arub- 
drub." He could catch very few words. In ordinary conversa- 
tion, familiar short sentences were apprehended readily; equally 
simple sentences, containing other than the most commonplace 
words, had to be repeated again and again. Reading from a 
book was jargon to him. Writing from dictation was impossi- 
ble, and even the alphabet was poorly executed in this way. 
The sound of the letter c seemed the one for which he was 
most deaf. 

Yet his hearing was not impaired (I never tested it carefully), 
and he understood and appreciated music. While a lecture or a 



522 LOCALIZED CEREBRAL LESIONS. 

sermon was unintelligible, he enjoyed a concert and claimed to 
appreciate it. He whistled and hummed airs correctly — much 
better than he spoke. 

I often questioned about and tested him for hemiopia, with 
negative results. Occasionally he had attacks of moving fortifi- 
cation lines in the left fields of vision, but these were evidently 
phenomena of the migraine type. 

The pathology of the case is obscure in many respects. 

The arteritis (see Dr. Peabody's description) is not of the 
senile type, and the patient's statement that he had never had 
syphilis was positive, and, we believe, perfectly trustworthy. 
This would, therefore, be one of the best authenticated instances 
of non-specific endarteritis deformans, leading to obliteration of 
the calibre of small arteries, ischsemia of a cerebral territory, 
and softening.* 

The location of the lesion is peculiar, and some years ago 
would have been considered as destructive of the modern theory 
of aphasia. In view of the experiments of Ferrier, Munk.f and 
others, however, it seems clear that the lesion occupied a portion 
of the brain which is concerned in the reception of sensory im- 
pressions from various sources, more especially the eye and ear. 

So long as aphasia was looked upon as sometimes a form of 
motor disorder, a difficulty in the emission of language, and in 
other cases as dependent upon verbal amnesia, it was impossible 
to explain its production by a lesion of the parietal or sphenoi- 
dal lobes. In the last two or three years the elements of im- 
perfect perception of the written signs and spoken sounds of 
language — word-blindness and word-deafness respectively — have 
received some recognition, and these phenomena are perfectly 
explicable by lesions placed in the sensory or perceptive regions 
of the cortex and internal capsule. 

In such cases the aphasia is indirect, not due to any interfer- 
ence with the channel for the emission of sound-forming im- 
pulses, but to a break in the other part of the circuit, viz., the 
receptive organ. 

Dr. A. B. Ball, of New York, is the author of the article from 

- It is very much to be regretted that the cerebral arteries and the brain itself 
were not examined microscopically ; but the autopsy was allowed only on condition 
that the brain be not retained for examination. 

f Consult Ferrier, The Functions of the Brain ; New York, 1876 ; Munk, Ueber 
die Functionen der Grosshirnrinde ; Berlin, 1881. 



LOCALIZED CEREBRAL LESIONS. 523 

which the foregoing large extract is made, and my small share in 
it is the description of the lesion found in the brain, and some 
general remarks upon the pathology of aphasia. In this con- 
nection I quote from the article because the lesion seems to in- 
dicate the postero-inferior limit of the motor area of the hemi- 
sphere. Although a large part of the inferior parietal lobule, 
and the first tier of temporal gyri, together with the associated 
white matter, were necrosed, there was no permanent hemiplegia. 
At the beginning of the illness, for awhile after the attack, 
"slight paresis of motility" was noted. Whatever value this 
case may have for the study of indirect aphasia, it certainly will 
rank high as a negative case in the question of cortical motor 
localizations. 

Case V. — Abscess of the left frontal lobe of the cerebrum, without motor 
phenomena.* 

On April 11, 1880, I was asked by Dr. J. Lewis Smith to see a case in con- 
sultation with himself and Dr. J. R. Learning. The patient was a young mar- 
ried woman, aged abou£ 28 years, who had formerly enjoyed good health and 
had borne several children. During the month of February one of these 
children had died after a severe illness, and she had undergone considerable 
fatigue. She seemed depressed, weak, and ansemic afterward. 

About four weeks before the date of consultation she complained of pain 
over the left eye. This was soon accompanied by swelling and exophthalmus, 
and on March 24th Dr. Knapp was called in and diagnosticated orbital (sub- 
periosteal) abscess. This was opened on March 26th by Dr. Knapp. 

It was remarked that the pus was under great tension, and that it spurted 
out a considerable distance when released. Pain ceased at once, the exoph- 
thalmus disappeared, and the wound quickly healed. During the first few 
days of April all seemed going on well; the wound was healed; the patient 
was free from pain ; she was taking tonics, and on the 3d made a call on a 
near neighbor. 

During the night of April 3d and 4th, one week before my examination, 
she awoke with severe headache and A-omiting; ever since she has lain abed, 
presenting the following symptoms: Headache, chiefly mastoid and through 
the base of the skull; occasional vomiting; irregular respiration; irregular 
and very slow ]3ulse, varying from 60 to 50 beats per minute ; stupor and gen- 
eral feebleness. As negative points there were no symptoms about the eyes, 
objective or subjective, except a partial ptosis of the left upper lid (which had 
been incised) ; no fever, chills, convulsions, paralysis, aphasia; at no time had 
there been coma. The urine was free from albumen. 

Examination. — Patient was soporose, but could be roused by loud speaking; 
she answered questions as if half asleep, but in such a way as to leave no 
doubt as to the preservation of language. She put up both hands to the 

* See p. 452 ; also Archives of Medicine, vol. v., No. 1, Feb., 1881, p. 107. 



524 



LOCALIZED CEREBRAL LESIONS. 



mastoid regions when indicating the seat of pain. A minute inspection 
showed no paralysis except about the left eye, whose upper lid drooped and 
whose internal rectus was inert. The pupil on the left side was not fully 
dilated, but it was a little wider than the right. The optic nerves appeared 
somewhat congested, and were dim at their periphery, but there was no actual 
choking. Patient appeared to feel pinching well everywhere. The ther- 
mometer showed no fever. The pulse varied from 53 to 66 beats per minute, 
and it was a reluctant, delusively full pulse, with no real strength. The 
breathing was easy and regular, but friends of the patient described quite 
well a Cheyne-Stokes breathing which they had observed. There was neither 
redness nor tenderness about the site of the orbital abscess. 

I diagnosticated an abscess of the brain, probably in the left frontal lobe, 
and expressed the opinion that the patient was in imminent danger. She died 
the next day in a comatose state, no new symptoms having been observed. 



It was then learned that for two years Mrs. F. had suffered 
from frequent attacks of headache, lasting several hours. The 
pain was frontal, and sometimes extended along the nose and 
into the left temple. There had never been symptoms of chronic 
nasal catarrh. 

The autopsy was made by me on April 13th, about thirty 
hours post-mortem, in the presence of Drs. Knapp, J. R. Learn- 
ing, J. Lewis Smith (the attending physician), and Richard 
Wiener. We found a large abscess, the size of an English wal- 




Fig. 10.— Apparent location of the abscess, drawn on an Ecker's diagram of the brain. 



nut, in the left frontal lobe. It seemed to lie wholly under the 
cortex cerebri, in the convolutions of the orbital lobule, and in 
the second frontal convolution. Viewing the hemisphere from 



LOCALIZED CEBEBRAL LESIONS. 525 

the side, the apparent posterior limit of the abscess was the 
anterior border of the lower part of the third frontal gyrus. Fig. 
10 indicates the seat of the soft, fluctuating, bulging abscess. 
Its size and penetration were not then determined, as it was 
thought best to harden the brain as a whole before making 
sections. 

The external connections and origin of the abscess were most 
interesting. There was only one point of adherence between 
the diseased frontal lobe and the dura mater, and that was oyer 
the orbital plate of the frontal bone immediately under the 
swollen frontal lobe. There the dura mater was thickened and 
adherent to the pia mater and cortex cerebri, forming the infe- 
rior wall of the abscess, over a space as large as a ten-cent piece 
(about 15 mm.). Under this patch of pachymeningitis the orbital 
plate of the frontal bone was necrosed and perforated ; a probe 
was easily passed into the orbit. 

In the orbit, under its periosteum, pus was found, and a part 
of the roof and the inner wall of the orbit were carious. Careful 
dissection by Dr. H. Knapp showed disease of a similar kind in 
the ethmoidal cells and frontal sinus. I need say nothing more 
of the conditions of these parts and of the pathology of the 
orbital abscess, as the case has been fully reported from this 
point of view by Dr. Knapp.* 

The appearance of the necrosed orbital plate and of the thick- 
ened, adherent dura mater, was precisely similar to what I have 
several times seen in cases of suppurative disease of the internal 
ear with cerebral abscess by contiguity. The genesis of the 
abscesses must have been alike in the two situations. 

In December, the brain having been sufficiently hardened in 
bichromate of potash solution, I embedded it in Gudden's micro- 
tome, and made several horizontal sections through the whole 
brain with the view of demonstrating the relations of the abscess. 
These cuts showed that the abscess was of quite as large a size 
as at first supposed, almost perfectly globular in shape, meas- 
uring about 38 mm. in diameter. It contained ordinary pus, 
and was lined by a distinct membrane 1-2 mm. thick. The 
anterior, inferior, and external limits of the abscess were thinned 
cortex and pia mater ; superiorly, posteriorly, and internally, it 
was bounded by apparently normal white substance. The whole 
of the white centre of the frontal lobe, except a portion near the 
* Archives of Ophthalmology, vol. ix., p. 185. 



526 LOCALIZED CEREBRAL LESIONS. 

convexity of the hemisphere, was destroyed to within 10 mm. of 
the folds of the island of Reil, and about 8 mm. of the head of 
the nucleus caudatus. The mass of white substance connecting 
the inferior and posterior part of the third frontal convolution 



• Fig. 11. 
Relations of the abscess as shown in a horizontal section of the brain made at the level of Broca's 
speech-centre. Drawn from a photograph of the specimen. Occipital lobes cut off. 

and the anterior gyri of the island of Eeil with the internal 
capsule, was uninjured. 

This fact is of capital importance in estimating the bearing 
of this case upon the current notions of cerebral localization. 

The above description of the topography of the lesion, 
especially its posterior limitation, is made from the surface 
exposed by the lowest cut made, viz., one passing through the 
speech-centre of Broca, about 10 mm. above the apparent com- 
mencement of the fissure of Sylvius (pia still adherent). Fig. 11 
is faithfully drawn from a photograph taken of this section- 
surface. The rest of the brain was healthy to the naked eye. 

This remarkable case seems to me of much importance as a 
negative contribution to cerebral localization. It is in exact ac- 
cord with recent experimental data, and with the post-mortem 
findings of the last ten years, that an abscess placed like this 
one should give rise to no motor symptoms, and should not 
cause aphasia. It is wholly within what are now called the in- 
excitable districts of the brain. The only symptoms present 
were the partial paralysis of the left third nerve (more imme- 
diately caused by the orbital abscess ?) and signs of intracranial 



LOCALIZED CEREBRAL LESIONS. 527 

pressure. Yet it is important to note that in spite of the enor- 
mous pressure which must have existed, there was no actual 
neuro-retinitis. 

I have elsewhere reported another case of (smaller) abscess in 
precisely the same location (left frontal lobe) in which no symp- 
toms referable to this lesion were present.* 

On the other hand, numerous autopsies are on record in which 
a smaller lesion (softening, hemorrhage, etc.), placed a centi- 
metre further back in the left frontal lobe, involving the pos- 
terior part of the third frontal gyrus or the band of white sub- 
stance between it and the nucleus caudatus, has given rise to 
severe symptoms, hemiplegia or aphasia, singly or combined. 

In the paper just quoted I have described such cases. 

This case has the same negative importance as Case IY. ; serv- 
ing to indicate the anterior limit of motor activities in the 
hemisphere. It shows that the lower part of the first and 
second frontal, and the orbital lobule of the frontal lobe, have 
no direct motor connections with peripheral parts of the body ; 
and, also, that these regions of the brain are non-excitable. 

CONCLUSIONS. 

The following conclusions may be legitimately drawn from the 
cases of localized, cerebral disease (twelve in number) which I 
have published in the last four years : 

1. The motor area of the cerebral cortex and allied white sub- 
stance extends anteriorly as far as the lower half of the second 
and first frontal gyri, and posteriorly as far as the anterior part 
of the interparietal fissure. This statement is justified by Case 
VII. of my first paper (lesion of the left frontal lobe), and Cases 
IV. and V. of the present paper.' 

2. The region lying between the limits indicated above, the 
middle regions of the hemisphere, on its convexity and (to a 
certain extent) on its median surface, including the posterior 
parts of the first and second, the whole of the third, frontal gyri, 
the whole of the ascending frontal and ascending parietal gyri, 
with their terminations in the longitudinal fissure known as the 
paracentral lobule, with probably the upper parietal lobe — all 
these cortical parts, with their associated segments or fasciculi 

•- Seep. 220; also Transactions of the American Neurological Association, 
vol. ii„ pp. 122-4, N. Y., 1877. 



528 LOCALIZED CEREBRAL LESIONS. 

of white matter, have strong motor functions, being in direct re- 
lation with the muscles of the face, tongue, arm, and leg. This 
general statement is supported by the remaining nine cases in 
the two essays, in which destructive lesions of this area gave 
rise to spasm or paralysis on the opposite side of the body. 

A further and more elaborate induction is permissible from 
these nine positive cases : 

a. The lower part of the third frontal gyrus is intimately con- 
nected with the organs of speech (and the function of language). — 
Gases L, II., III., and IV. of former essay. . 

b. The middle parts of the ascending frontal and ascending 
parietal gyri are directly connected with the arm of the opposite 
side. — Case Y. of first essay, and Case I. of present paper. 

c. The upper or posterior part of the ascending frontal and 
ascending parietal gyri, and the paracentral lobule (also the 
upper parietal lobule ?), are directly connected with the lower 
and upper extremities of the opposite side, and perhaps more 
closely with the leg. — Case VI. of first essay, Cases II. and III. 
of present paper. 

I cannot offer any case bearing on the questions of the loca- 
tion of the facial and ocular centres ; though I now have under 
study a living case of exquisite epileptiform facial monospasm, 
which has been controlled by a strict bromide treatment. 



ON THE USE OF A EEEBLY ALKALINE WATER AS A 
VEHICLE FOR THE ADMINISTRATION OF THE 
IODIDE AND BROMIDE OF POTASSIUM, ETC. * 

One hears a great deal in remarks and debates at medical 
societies and in private consultations of the gastric derangement 
produced by remedies which are of constant use and of unsur- 
passed efficacy, viz., the iodide of potassium and the various 
bromides (more especially the bromides of potassium and 
sodium). This evil result, or the dread of it, is not infrequently 
interposed against the free use of these salts in large doses for 
the relief of serious symptoms. 

For example, a patient lies comatose from cerebral syphilis, 
and when the advice is given to administer .18-25 potassium 
iodide every two or four hours, the attending physician very 
oft3n expresses his fears that great gastric derangement will 
result, interfering with the digestion of food. I have known the 
recovery of such a case placed in the greatest jeopardy by such 
a dread of the local effect of this remedy. 

Again, a patient is allowed to have recurring attacks of 
epilepsy while using small doses of potassium bromide, whereas 
by giving larger doses the paroxysms might be indefinitely sus- 
pended. The larger doses are not given partly from a fear of 
bromism in general, but also, I am convinced from numerous 
consultations, because it is believed that the bromides cause 
gastric catarrh. 

I am perfectly ready to admit that the salts in question may 
and do cause gastro-intestinal disorder, but I have very rarely 
observed this in my practice during the last three years. Hav- 
ing, as I believe, found the means of administering the iodide of 
potassium and the various alkaline bromides in a harmless way 
(as regards the digestive organs), I fancy it may be of some 
utility to give a detailed account of my plan of administration. 

This plan includes the almost equally important conditions : 

1. The use of a simple aqueous solution of the salt. 

* Reprinted from the Archives of Medicine, vol. vi., No. 1, August, 1881. 
34 



530 ALKALINE WATER AS A VEHICLE. 

2. Its ingestion upon an empty stomach (fifteen or thirty 
minutes before food). 

3. Its very free dilution with an alkaline solution. 

I. The importance of employing absolutely simple solutions of 
certain remedies, especially of the bromic and iodic salts, is 
being more and more realized by physicians, and the nauseous 
and, as I believe, indigestible mixtures which were imposed upon 
the profession by high authorities some twenty years ago, are 
passing out of use. Certainly, in the case of drugs whose reme- 
dial effects are as special and relatively simple as are those of the 
bromides and iodides, it would seem, a priori, that giving them 
in the shape of an aqueous solution were best. Their efficacy 
can hardly be increased by the addition of other drugs, and their 
taste certainly cannot be covered up or neutralized by infusions? 
syrups, etc. It has been my practice for several years to employ 
a solution of iodide of potassium made by dissolving equal parts 
by weight of the salt and of water. Experimenting upon a 
considerable bulk, it has been found that there is a loss by 
volume of one-fifth in mixing the salt and water. In other 
words, a drop of this solution contains about .05. A patient 
who takes a dose of one hundred drops of this solution does not 
in reality receive (as is often erroneously stated) 6. of the salt, 
but only about 5. This difference is of considerable importance 
in the treatment of cases requiring the maximum doses of iodide. 
Of this solution I direct that so many drops be given in the dilu- 
tion to be presently described, about half an hour before meals, 
or before food. 

The bromides I have for some years prescribed upon one 
general or typical formula, varying the ingredients to suit differ- 
ent cases, but keeping the standard dose the same. This will be 
at once recognized as of great utility in treating a large number 
of cases of epilepsy in private and in hospital practice. It is 
needless to defend the use of a standard formula from the charge 
of routine practice, because reflection will show that with such a 
type formula, the doses for each case can be varied infinitely by 
subdivision and arrangement of quantities of the solution. This 
general formula is : 

R Potassii bromidi, 45. 

Aquae, - - 200. cc. 

A teaspoonful contains 1. of the salt. 



ALKALINE WATER AS A VEHICLE. 531 

Another formula, which I often employ, is : 

1^ Ammonii bromidi, - - 15. 

Potassii bromidi, - - 30. 

Aquae, - - 200. cc. 

Of this solution also a teaspoonful contains 1. of the salts. 

All of my anti-epileptic solutions are constructed upon this 
type : one teaspoonful containing 1. of the salts. Perhaps the 
formulas require some explanations. They are not intended as 
examples of mathematical accuracy in dosage, such as would 
avoid an error of .06. They are constructed for practical use in 
families, and calculated upon the average capacities of teaspoons. 
These utensils no doubt vary in capacity, but from my own ex- 
periments, and from the testimony of others, medical and non- 
medical witnesses, I have been led to assume that only about 
seven teaspoonfuls could be obtained from 30. cc. of solution. 
Each of my standard bromide formulas contains, practically, 49 
doses, which, divided into the total quantity of salts, yields a 
quotient of very nearly 1. The translations into the metric 
system also need a word of explanation. They are correspond- 
ing and logically equivalent translations, and not all literal 
translations, such as abound in medical books and periodicals 
— translations absurdly exact, and only serving the purpose of 
disgusting physicians with the use of the metric system in pre- 
scriptions. 

Of these various bromide solutions, I direct one or more 
teaspoonfuls, properly diluted, to be taken upon an empty 
stomach. 

II. The idea of giving the iodides and bromides on an empty 
stomach is in no wise new, but is in opposition to what I think 
is the general practice. Influenced by the (delusive) notion that 
iodides and bromides produce gastric irritation, most practi- 
tioners give them after eating, when they probably undergo 
more rapid decomposition, and interfere with the process of 
digestion. 

Deposited into an empty stomach, which in normal conditions 
presents a neutral or alkaline reaction, more especially if 
guarded by an alkaline liquid, it is a practical reality that these 
salts are very efficacious, and that they cause no gastric irritation. 
Theoretically it is almost demonstrable) that they are absorbed 



532 ALKALINE WATER AS A VEHICLE. 

quickly, wholly, and with little if any change. The contact of the 
solution may act as a solid body or a portion of aliment, and 
cause an outpouring of acid gastric juice ; this is, however, not 
proven, and if such an event does occur, the acidity thus produced 
will be antagonized by the alkaline salts of the solution. 

III. While serving as resident physician in the New York 
Hospital in 1865-7, I noted the addition of potassium bicar- 
bonate to prescriptions for potassium iodide by some of the 
visiting staff. I did this myself in practice afterward, but 
found objections to the device in that it caused the insertion of 
one more ingredient in a formula which might already be complex 
enough, and in that often too much alkaline salt was given. 
Some five years ago I began directing patients to measure out 
their dose of bromides or of iodide into a glass, and add a liberal 
quantity of Yichy water, from one-half to a whole glassful. 
Gradually I adopted this as a vehicle in all cases, and now 
testify to the excellent results of this practice from a three years' 
large experience. When the patient resides in a city or large 
town, I direct him to procure the artificial Vichy water in 
siphons, which is now so widely manufactured. Some of these 
imitation waters are very honestly made nearly like the known 
composition of the waters of Yichy, and others, the majority, I 
suppose, are carelessly compounded. At any rate, the siphons 
contain a solution of bicarbonates of sodium and potassium 
highly charged with carbonic acid gas, and this is sufficient for 
our purpose. For patients living where the siphons cannot be 
procured, or for patients who travel much, I direct the purchase 
of the effervescent Vichy salts, either of American or foreign 
manufacture. A teaspoonful of the salts in a glassful of cold 
water, makes a sparkling glass of Vichy water, in which the 
medicine can be mixed. 

In the case of patients who cannot afford to buy these prep- 
arations, I recommend that a good-sized pinch of bicarbonate 
of sodium be added to a glass of water. The advantages which 
I claim for this method of giving bromides and iodides in weak 
alkaline waters surcharged with carbonic acid are two-fold : 

First, the supposed irritating effect of the salts upon the 
gastric mucous membrane is reduced to a minimum, if not ab- 
solutely neutralized. This statement is theoretical, but, prac- 
tically, I am able to state that I almost never observe gastric or 
gastro-intestinal disorder while giving full or even very large 



ALKALINE WATER AS A VEHICLE. 533 

doses of the salts to patients of various ages. I am thus enabled 
to administer from 5. to 10. of the bromides in the day ; and 
even when bromism occurs, the gastric symptoms are almost 
nil. The iodide of potassium I have thus given in doses varying 
from small doses to 32. in the day, without indigestion. Occa- 
sionally for severe cerebral symptoms, I have caused children to 
have a dose of 5. three times a day, with only good results. 

Second, the taste of the bromides and iodides is considerably 
masked by the sparkle and sub-acid taste of the effervescent 
drink. Mauy patients have thanked me warmly for having 
substituted a simple solution of bromides (or of iodide of potas- 
sium) given in Yichy water for the classical mixtures which they 
had formerly taken. 

I should add that the salicylate of sodium is well taken in 
this way : a powder of the size required, 1. to 3., is dissolved 
in a glassful of Yichy water. This covers the disagreeable 
sweetish taste of the salt, and I believe, favors its complete 
absorption. 

In some simple cases of epilepsy I give only one dose of 
bromide of potassium in the day, at bed-time or on rising. In 
such cases I prescribe the medicine as a powder of from 2. to 4. 
or more, to be taken in a glass of Yichy water. 

In some neurasthenic cases, and some cases of oxaluria with 
insomnia attended by restlessness, I have obtained excellent 
results from the use of a powder containing (usually) 2. each of 
salicylate of sodium and bromide of potassium taken in a glassful 
of Yichy water. 



HISTOEY OF ATTEMPTS MADE TO CUKE THKEE 
CASES OF CHEONIC TEIGEMINAL NEURALGIA * 

It must have appeared to many physicians besides myself 
that the custom of reporting only successful cases, and of slight- 
ing, or altogether omitting, an account of our unsuccessful 
attempts at cure, was a bad one, and this for several reasons. 
One of these is that the perusal of such one-sided reports is 
quite sure to inspire some of our confreres with undue confidence 
in the power of drugs over disease, and to shape their prognosis 
accordingly. 

Among the diseases which most tax our patience and thera- 
peutic skill, there are few more redoubtable than chronic tri- 
geminal neuralgia, or tic douloureux. Excellent as is the 
reputation of this affection for incurability, yet the published 
records of this committee embrace several instances of its cure 
by drugs in patients who had suffered fourteen years or less 
(vide New York Medical Journal, December, 1878, p. 621). 

I propose this evening, for the purpose of enabling you to 
profit by my unsatisfactory experience, to relate briefly the 
history of three cases of the disease in question which have not 
been cured. 

Case I. — Mr. F. O., aged 45, oyster dealer. History taken when first seen, 
Dec. 12, 1878. General health has always been excellent. In 1856 had a 
single malarial chill, followed by two slight attacks of right supra-orbital 
neuralgia. 

Present tic douloureux began in 1857, by a few " sticking" pains near the 
right infra-orbital foramen : a single pain like the pricking of a needle several 
times a day. This pain steadily increased in severity and frequency. Came 
north from Georgia in 1858, and for one year was free from pain. After that 
time it returned. Two or three times a year afterward he had spontaneous 
relief for some weeks. In the last two or three years constant suffering. 
Patient has tried a good many medicines without relief. 

Now has a paroxysm of pain every two or three minutes, day and night. 
Eating, drinking, talking, attempts to wash or wipe the skin of the face on 
right side excite paroxysms of pain. 

About, three years after commencement of trouble (1857) the pain extended 

* Reprinted from the Archives of Medicine, vol. vi., No. 1, August, 1881. 



INTRACTABLE NEURALGIA. 535 

to the whole of the upper maxilla, later to the lower jaw, and recently the 
whole of the right trigeminus, lingual branch included, has been the seat of 
pain. There is no regularity or periodicity in time of appearance of the pain, 
or in its degree of intensity. The patient never has common headache or 
dizziness. In 1857-58 one tooth was pulled from the right upper jaw, and 
another in 1867 ; pain aggravated each time. 

Denies injury to face and syphilis. 

Examination. — Patient is a large and powerful man, of healthy aspect, with 
a facies indicative of suffering. Every few minutes he has an epileptiform 
(i.e., sudden) onset of pain in right side of face and head to vertex ; pain 
sharp and cutting; paroxysm lasts a few seconds, and during it the face flushes. 
The cutaneous sensibility of the affected region is normal to simple touch and 
to aBsthesiometer test. Hearing of right ear O, drum thick and whitish. 
Hearing of left ear 30-38 cm. (watch). The corneas are normal ; right pupil 
is a trifle smaller than the left in intervals between pains. The teeth on right 
upper and lower jaw's are covered with an extraordinary layer of "tartar." 
and some are loosened. Patient has not dared cleanse teeth on that side for 
years. There are no tender points upon the face or in the mouth. Teeth on 
the left side are fairly clean. 

Was ordered solution of Duquesnel's crystallized aconitia, in doses of .001, 
and this was given in increasing doses, with no relief. On December 18th 
following note recurs : Aconitia must be deemed a failure. Has taken .006 
in 24 hours. Constant great effects on sensory nerves, coldness and tingling. 
Has pains almost every two minutes. Fowler's solution ordered in increas- 
ing doses after meals. December 30th. Has increased arsenic solution to six- 
teen drops after each meal ; nausea ; no relief to pain. 

Ext. gelsemii fluid ordered December 30th, five drops before each meal, and 
at bedtime. January 14 (1879), full effects of gelsemium obtained from doses 
of fourteen and fifteen drops four times a day. No relief to pain. 

Sol. phosphori, Thompson (teaspoonful containing .003 of phosphorus), tried 
ih doses of 4 cc. an hour before each meal for several days ; no effect. 

Injections of chloroform in cheek used on January 20th, 21st, and 22d. 
Injections made through mucous membrane, toward right infra-orbital nerve. 
.30 on 20th, .60 on 21st, with no relief; slight swelling and burning pain. 
Attempt to inject 1. cc. on 22d resulted in asphyxia, and apparent death, 
previously reported to the committee. 

Mixed treatment, iodide of mercury and saturated solution of iodide of 
potassium, ordered on January 23d. On February 11th slight effect on gums 
is noted ; takes about forty drops of sol. sat. KI. three times a day ; no relief. 

Galvanism, stabile, strong current (25 cells) ; cathode on tender points from 
7 to 15 minutes. Patient thinks pain is aggravated by the current. 

Ammonio-sulphate of copper ordered, .08, with ext. cannabis ind., .03, before 
each meal since February 11th; stopped on 15th; no relief. 

Operation. — Resection of right infra-orbital nerve performed in February. 
Nerve removed outside and inside orbit. Healed by primary union. 

March 9th. — Face perfectly healed; only part that is absolutely anaesthetic 
to faradic current by brush is a spot about 2 cent, square under right eye. 
Has partial sensibility to brush, and pricking in rest of cheek, in ala nasi, and 



536 INTRACTABLE NEURALGIA. 

upper lip, and inner aspect of cheek and mouth. To-day less pain, but he 
suffered very much on 6th, 7th, and yesterday. A paroxysm seen in office 
seems less severe than those before operation. Ordered quinia sulph., .25, 
morphia sulph., .02, three times a day. 

March 14. — Much better. Few attacks in supra-maxillary region. Talking 
and chewing can be done without agony. Has had several severe attacks of 
pain in infra-maxillary region, and in outer part of orbit ; not in supra-orbital 
district. Has had good nights. Continue quinia and morphia. 

March 19.— Is fifty per cent, better than before operation (patient's own 
estimate). 

March 28th. — No " neuralgic " pain in right upper jaw and lip, but the 
lower jaw and lip are seat of severe neuralgic pains, not as severe as formerly. 
Ordered pil. quinise et morphise et belladonna? twice a day. Ordered fluid 
extract of aconite, one drop t. i. d. 

March 31st. — No neuralgic pain in upper jaw ; severe in lower jaw. Con- 
tinue aconite. 

April 14th. — Considers his condition improved at least 50 per cent. Takes 
.25-. 30 tincture aconite, with slight physiological effects. Sleeps soundly. 
No severe paroxysms in two weeks. 

During May more pain ; severe paroxysms in anaesthetic district. Fowler's 
solution, aconite, morphia again tried in vain. 

Was not seen again until December 17, 1880. Was free from extreme suf- 
fering for several months. In last few months almost constant severe pain. 

I have since tried aconitia and gelsemium to jDhysiological effects, without 
relief. 

Dr. Weir is planning to remove Meckel's ganglion.* 

Case II. — Mr. H. S., janitor, aged 29 years. History of case taken Octo- 
ber 2, 1878 (vide a partial report on the case in New York Medical Record, 
January 4, 1879, vol. xv., p. 7). 

Previous to the development of the present affection, he had been subject 
to occasional dull headaches. Ten years ago (18G8) he suddenly experienced 
a very severe sharp pain all through his head, " as if devils were at work 
there, " lasting half an hour. There was no dizziness or f aintness, or nausea, 
or impairment of sight, or paralysis. For a p>eriod of six months he remained 
free from pain, and, indeed, was perfectly well. After that time, nearly ten 
years ago, a "dull, stupid pain" began over the right eye, extending from 
the supra-orbital notch inward to the nose, and down the side of the nose to 
the ala nasi. This pain was paroxysmal, and worse in the daytime. Later 
the pain extended to the eyeball, and was exceedingly severe, the paroxysms 
recurring from ten to twelve times a day. In the course of two or three years 
the pain made its appearance in the right temple — worse at night. 

In the last few years most of the pain has been on the top of the head, above 
the temple, and in front of the ear to the bregma. There has lately been only 
an occasional pain in the side of the nose, and not much pain in the temple 
proper. During the past summer, and since, there has been some occipital 
pain on both sides — more on the right. In the last year there has also been 

* The operation was subsequently done with relief.— [R. W. A.] 



INTRACTABLE NEURALGIA. 537 

pain in both the upper and lower jaws, in the upper lip near the median line; 
none in the tongue (on right side). In the last four years vision has been 
dim, and glasses have not remedied the defect. Five years ago had temporary 
diplopia, but this was while taking some unknown medicine. At various times 
during this long illness has had " dizzy spells," with varying frequency; few 
in the last months. Has had no other symptoms of a neuralgic nature. 
Memory is impaired and virility quite lost. Had severe dyspepsia and vomit- 
ing three years ago, and has been costive during the whole period of the 
disease. 

Examination. — The various painful regions are hyperalgesia but not numb, 
and the tactile sensibility is perfectly preserved on both sides. There is no 
facial paralysis ; the right pupil is positively small, the left normal. After 
dilatation by atropine opthalmoscope reveals no lesion in the fundus. Hearing, 
smell and taste are normal. Cornea clear. The urine (frequently examined 
by other physicians and found normal) is now free from albumen. Marked 
anaemia is exhibited by the skin and mucous membranes ; has always been 
pale; denies syphilis. 

The pains, which occur frequently in my office, are the most terrible which 
I have ev(y witnessed ; the patient fairly writhing in his chair, or even falling 
to the floor (not unconscious) in his agony. During the attack the right eye 
is much injected, and tears flow freely from it, while the left eye remains dry. 

The patient states that no medicine has ever relieved him, and that he has 
tried a great many. 

The treatment in this case, though prolonged until now, February, 1881, 
has been relatively simple. 

Duquesners aconitia in doses of .000G. Solutions by Neergaard at first, later 
in the shape of Schieffelin's granules, given from two to four times a day. 
Full physiological effects were easily obtained, and Avere kept up for many 
months. Numbness and a remarkable cold chilly condition were the signs. 
At times the subjective cold was so great that he would come to my office 
shivering in an overcoat. 

In this case, as in Case III., increased susceptibility to the action of the drug 
was observed as time went by. In the last few months one dose of .0006 
produces effects which last from six to nine hours. 

Besides aconitia, iron and Fowler's solution in moderate doses have been 
administered frequently. Has had several attacks of subacute rheumatism 
rapidly cured by sodium salicylate." 

On the whole the result obtained is very gratifying — it is a relative cure. 

Patient a few weeks after beginning of treatment experienced no excru- 
ciating paroxysms and gradually resumed his occupation as janitor. In last 
few months seldom loses half a day. Has kept a record of attacks, classifying 
them into severe and mild; has had very few severe ones in each month, and 
has registered many days without any pain. 

There has occurred a curious shifting of pain. It was formerly more 
intense in fronto-temporal region, it is now developed mostly near the parietal 
eminence. 

The patient's general condition has greatly improved; he still has a 
peculiarly white skin, bat his lips, etc., are fairly well colored. 



538 INTRACTABLE NEURALGIA. 

The change in moral is most remarkable ; is now cheerful, and enjoys both 
his work and his family pleasures ; whereas about a year ago he looked upon 
life as a burden. 

Case III. Mr. W. L. P., clerk, aged 54 years, seen September 22d, 1880. 

Had always enjoyed good health. 

In 1876 there • appeared a pain in front of the right temporo-maxillary 
articulation; a deep pain. At first the pain was occasional, excited by wash- 
ing face. Pain has steadily increased in frequency and severity, until now 
paroxysms occur almost every moment. The pain is rather worse in afternoon 
and night, not typically nocturnal. In about a year after beginning, the pain 
extended to infra-maxillary and infra-orbital nerves (never appearing at 
mental foramen). It extends into the gums in right upper and lower jaws, 
and " strikes" in the lower jaw at a point a little posterior to the angle of 
the mouth. No pain above zygoma and orbit. Saliva flows in the paroxysms. 
All movements of jaw cause more pain. Weather is without influence. 

No malarial fever since his 16th year. Never had syphilis. Used much 
tobacco until recently. Temperate. Has had seven teeth pulled from the 
right upper jaw without relief. * 

Examination. — No tender point, except at the mental foramen, wjiere there 
is no pain. No evident anaesthesia. Some atrophy of fatty tissues of face on 
the right side. Opening mouth causes a paroxysm. Hair on face kept 
stubby, and is worn on cheek by constant friction of hand and fingers during 
paroxysms. Attacks last from one to one and a half minutes. General 
health good. 

The treatment was began September 22d, by giving Duquesnel's crystallized 
aconitia, in the shape of tablets made by Caswell & Hazard, .0003, every two 
hours. 

25th. — No strong aconitia effect. Sleeps without chloral. Ordered, .0003 
every hour. To-morrow .0006 every two or three hours. 

27th.— Great relief; did not feel aconitia much, .0006 every two hours till 
5 p.m., when he was quite numb, and sight was dim. 

29th. — Marked improvement; pain only in zygomatic region. From the 
29th to October 1st, included, sol. phosphori Thompson was used, teaspoonful 
three times a day. Pain made worse. Again given .0006 aconitia. 

Oct. 4th. — Severe pain; no aconitia for one day. Takes sol. Fowler., eight 
drops after each meal, increasing. Ordered continue Fowler, and take ext. 
gelsemii fid., five drops every two hours. Continue and increase the Fowler's 
solution. 

10th. — Ext. gelsemii fid. is being used, but no aconitia. Takes eight drops 
of gelsemium every three hours with moderate effect ; double vision at times ; 
lids heavy. Very little severe pain ; has lost habit of rubbing cheek in parox- 
ysms; good nights. 

20th.— Has reached a maximum dose of sixteen drops Fowler's after each 
meal. Gelsemium as above. The gelsemium is stopped ; Fowler's continued, 
and aconitia, .0006 every two hours, ordered. 

23d. — Very little pain in last forty-eight hours ; feels the aconitia ; attacks 
slight; pain nearly localized near right temporo-maxillary articulation; can 
eat and talk with little pain. 



INTRACTABLE NEURALGIA. 539 

Iodide of potassium, saturated solution, in doses of twenty drops before 
each meal in much water, increased by five drops daily, was begun on 28th. 
Fowler's abandoned. Aconitia, .0006 p. r. n. 

Nov. 3d. — Coryza and hoarseness, neuralgia slight. Takes forty drops t. i. d. 
Stop. Cautery on focus of pain in front of ear tried on 5th. Pain aggravated. 

Ammonio-sulphate of copper was tried during November, December, and 
January (1881), given in pills, dose increased from .05 t. i. d. after meals, to 
.20 after each meal and at bedtime. Aconitia .0006 was usedj9. r. n. by 
patient all the time. 

Pain very variable ; a few days almost without pain ; other days much pain, 
often under influence of storm or rain. At one time copper before meals pro- 
duced griping and watery stools ; no ill effect when administered after food. 

Dec. 11th. — The note is made that patient has become much more sensitive 
to aconitia; is affected in ten minutes by one tablet, whereas formerly it re- 
quired an hour or more to obtain any prickling. 

The whole of January, 1881, was very comfortable. 

1st. — No severe paroxysms. Was in Canada part of the time. Now can 
use only one or two (.0006) tablets of "aconitia a day — formerly could take one 
every two or three hours. 

' Feb. 19th. — In last month gelsemium and aconitia. Much more pain in last 
fortnight, though not as much as before treatment. Pain is severe in spite of 
full effects of gelsemium, five drops every two hours. 

A fair summing up of these attempts at relief of incurable 
conditions is, it seems to me, that aconitia is the chief agent to 
be relied on for the alleviation of the pain of chronic trigeminal 
neuralgia, and for its cure. Of course, malarious and syphilitic 
neuralgias are excluded from this statement ; in them we have 
special indications. 

Gelsemium and arsenic have both seemed to exert a secondary 
beneficial influence. 

Galvanism, the actual cautery, injections of chloroform, were 
useless. Morphia and chloral afforded mere temporary relief. 



IMPOBTANCE OF THE EAELY EECOGNITION OE 

EPILEPSY.* 

The paper which I have the honor to submit to the Society is 
one which treats of an eminently practical subject, handled, I 
trust, in a practical manner. It is upon the importance of the 
early diagnosis of epilepsy in its principal forms. This essay is 
also a logical correlative of the one which I presented to the 
Medical Society of the State of New York in February of this 
year, upon the early diagnosis of some organic diseases of the 
nervous system.t 

My attention has for several years been attracted by the fact 
that most cases of epilepsy were allowed to go on for months or 
years, perhaps passing the stage of curability, without a correct 
diagnosis and proper treatment. The mistakes of this sort 
which come under the observation of specialists are very 
numerous, and many of them have been committed by leading 
members of our profession. I shall present a number of his- 
tories of cases illustrating these errors of diagnosis, and I would 
earnestly request my readers to bear in mind that I cite these 
mistakes only for the purpose of instruction, and not at all with 
the idea of fault finding, or of exalting my own diagnostic acumen. 
Several of the physicians referred to anonymously in the follow- 
ing pages are gentlemen who are really eminent as teachers and 
practitioners, and at whose feet I would be glad to sit. Their 
errors were not due to carelessness or ignorance, but to a too 
ready acceptance of medical laws which pass current, yet are 
wrong. . 

The subject in hand is really a very complicated one, and I 
cannot pretend, in a paper whose length is limited, to enter into 
full details concerning the diagnosis of all the forms of epilepsy, 
and of the various symptom groups which may be mistaken for 
it. To do this would involve a prolonged and minute discussion 
of many mooted points. 

* A paper read before the Connecticut State Medical Society, Reprinted from 
the Medical Record, Aug. C and 13, 1881, vol. xx. 
f See the Medical Record, 1881, vol. xix., p. 225. 



EARLY RECOGNITION OF EPILEPSY. 541 

All I can do is to show that in most cases even the first 
attacks of epilepsy, of grand-mal and of petit-mal, can be recog- 
nized as epileptic. 

I shall first relate cases in which the grand-mal, or regular 
spasmodic attacks, were allowed to go on without proper treat- 
ment for want of a correct diagnosis, and offer some comments 
on each case. 



Case I. — Female child, aged eleven years, seen May, 1881, Was always a 
bad sleeper, of a restless disposition, and irritable. Was easily made to turn 
pale under excitement. Nights disturbed by talking, crying, and even by 
nightmare. Five years ago the family physician regulated child's diet and 
instituted some simple treatment ; since which attacks of pallor have been 
infrequent — very rare during the past winter.' Never had chorea. Indiges- 
tion has been a prominent feature in the child's life; she was fond of sweets. 
The urine was often found laden with oxalate of lime, and once, last summer, 
a trace of albumen was discovered. 

As regards any tendency to epilepsy, it appears that the child's mother is 
very nervous, and that one of her brothers was epileptic from childhood, in 
consequence of a fall (?). 

In June of last year the patient travelled about somewhat, alone with her 
father, without the supervision of mother and nurse. Was probably a great 
deal exposed to the sun. On or about June 20th, in the early evening, while 
out on the grass, fell in a severe convulsion. Seemed in poor health after- 
ward, and the family physician, considering the attack as caused by indiges- 
tion, or at any rate as symptomatic, prescribed a strict diet and an occasional 
dose of calomel. 

On September 29th, in the cars, returning home from the country, was 
excited and overheated. After arriving at the house had her second attack, 
characterized by loss of consciousness, universal spasm, frothing at the mouth. 
Did not bite tongue, and was not inclined to sleep after fit. Traces of 
albumen in urine. Treatment was still directed to the disordered state of the 
digestive apparatus as a cause of the epileptiform attacks. 

A week later, October 6th, after some excitement, in presence of her 
mother, suddenly fell in a convulsion, lighter than the previous ones. 

After this a moderate bromide treatment was added to the management of 
the case, and no attack occurred until April 25, 1881. 

The bromides, though given judiciously and by a very skilful hand, pro- 
duced irritability and other disagreeable symptoms, which led the child's 
mother to cease giving them some time in January. 

An attack on April 25th was characteristic, but slight, and followed by 
sleep. After it urine found laden with oxalate of lime. 

May 2d, while the child was being prepared for bed, she felt some warning 
sensation (not a definite one) ; rushed, nearly undressed, to her mother, stood 
speechless before her, and was slightly convulsed in the throat. 

A sixth and last attack occurred in the evening of May 8th. Sat in a spasm, 



542 EARLY RECOGNITION OF EPILEPSY. 

foamed at the mouth ; was rigid one instant, and then had clonic spasms of 
extremities ; face not convulsed (?) ; pupils not observed. 

There have been no " dizzy spells " or petit-mal. 

It is needless to add that I advised a resumption of the bromide treatment 
in this typical case of epilepsy, with special precautions against severe bromic 
symptoms. 

This case is peculiarly instructive, because the physician who 
treated it as one of lithsemia and oxaluria, with symptomatic 
convulsions, is an unusually intelligent practitioner and a gentle- 
man of high standing in the profession. His judgment was 
warped by the currently accepted notions of the frequency of 
eclampsia. 

Case II. — Mrs. C. S., aged thirty-four years, seen March, 1879. Former 
health good. During 1876-77 she had had much malarial fever, irregular 
chills, and attacks of fever. 

In April, 1878, after having been confined to the house by an attack of 
fever, she had a first convulsion. This occurred in sleep, after dinner, at 
about 2 o'clock p.m. It was a full convulsive seizure, in which she bit her 
tongue, fell heavily from the lounge on which she was lying, and hurt her 
face. m 

A second attack recurred on the night of August 2d. She groaned, was 
convulsed, frothed at the mouth, and bit her tongue. 

A third attack of grand-mal occurred in the night of January 1-2, 1879. 
This was less severe, but she bit her tongue. 

Has had few attacks of petit-mal, consisting in momentary confusion. 

The significance of the first attack was ignored in this case, and a bromide 
treatment was not begun until after the second seizure. Since then has had 
bromide irregularly, at times too little, sometimes none at all, and occasionally 
too much. 

Etiology obscure. Owing to patient's age and the absence of any inherited 
tendency, I inquired particularly as to symptoms of syphilis, with negative 
result. Frequent examinations of the urine have shown no sign of renal dis- 
ease. As regards syphilis, the subsequent course of events, improvement 
without mercury or iodide of potassium, has justified my conclusion at the 
time of my examination. 

It is sufficient to state, with respect to treatment, that Mrs. S. was put on a 
careful course of chloral and potassium bromide, which last year was changed 
to ammonium and potassium bromides. She has never required very much 
of the anti-epileptic medicines, and at times has had various tonics. 

To the present time, May, 1881, a period of twenty-nine months, she has 
had no attack of either kind, and her general health is excellent. Since 
the beginning of the year I have made a small reduction in the amount 
of bromide, and intend to make a further reduction every three months. Her 
present dose of the mixture of ammonium and potassium bromides is ,50 on 
rising and 2.5 at bed-time. 



EARLY RECOGNITION OF EPILEPSY. &4B 

If, after exclusion of uraemia and syphilis, the first attack had been diag- 
nosticated as epileptic, and treatment instituted, the probability of cure would 
have been greatly enhanced. The next case is an illustration of this state- 
ment. t 

Case m. — Miss F. 0., aged sixteen years, seen May. 1878. A well-devel- 
oped, healthy girl, menstruating since three years, with, little pain. Mother 
neurasthenic ; one brother had an exquisite attack of articular neuromimesis 
(both ankles). Patient never hysterical. 

Yesterday. May — . menses were flowing, when, in order to be able to go 
with comfort to a dancing-school soirte. she used a cold foot-bath and checked 
the flow. She danced a good deal in the course of the evening, and then 
took supper. To-day arose late, and seemed languid. About seven p.m. had 
a severe fit ; gave a cry, lost consciousness, fell heavily ; body was rigid and 
pupils wide open, then had clonic spasm, frothed at the mouth, and bit her 
tongue ; was stupid and sleepy after attack, whose actual duration was not 
timed. It was witnessed by a very intelligent young gentleman, who gave 
me the above particulars. I saw the patient at eight o'clock — one hour after 
the fit. She was conscious, complained of headache, of soreness in body gen- 
erally, and of her bitten tongue. The pulse was rapid, the axillary tempera- 
ture was over 37.8" C. : the patient's face and neck were covered with numer- 
ous minute petechia? resembling flea-bites; menses had returned. 

The seizure was typically epileptic. I anticipated a return of attacks only 
at the menstrual periods, and consequently instituted a rather peculiar treat- 
ment, which was carried out with unusual faithfulness. Bromide of potas- 
sium. 1.50. was to be taken night and morning for ten days, including the 
menstrual period : beginning three or four days before it ; and the patient 
was to be kept in bed or on the lounge for two or three days at the beginning 
of the flow. 

A few days ago (May 14. 1881) I had a note from the patient's mother, 
stating that her daughter had never had a return of spasm (or any other epi- 
leptic manifestation', and that she was still keeping quiet for two days in the 
menstrual week, and taking bromide of potassium. 

This makes an interval of more than three years, and I must say that I con- 
sider a return of attacks exceedingly unlikely. Still I have recommended 
continuing the periodical treatment for six or eight months longer. 

Case IV. — Air. C. D . aged twenty-one. seen February. 1877. Patient 

is a large and well-developed young man, something of an athlete. Former 
health good, but hygiene bad ; used wine and tobacco from twelve to eighteen 
years, and probably committed sexual excesses. Xo epilepsy in family ; 
mother subject to migraine: patient not. Xo dizzy spells. Head not injured. 

First attack occurred when he seemed in good health, on Christmas day. 
1873. Was sliding down hill, when he lost consciousness and fell off the 
sled, remained stiff for a few minutes, and was sick at his stomach. From 
his knowledge of the circumstances and from what he was told, the patient 
is positive that the fall from the sled was not accidental, but that he first 
" fainted." In two or three days was well. 

Remained perfectly well for ten months, and had a second attack in Octo- 
ber. 1874. Was sitting chatting with friends : lost consciousness, became 



544 EARLY RECOGNITION OF EPILEPSY. 

sick at the stomach ; did not bite his tongue. Had muscular soreness the 
next day. In the summer of 1875, after rowing on Lake George, had a third 
attack, without aura ; fell off a dock into the water. Fourth attack in May, 
1876, preceded by an undefinable preliminary sensation ; attack was agnni ac- 
companied or followed by vomiting. Fifth attack in October, 1876. This was 
treated by Dr. X., as stated in the letter which is appended. Another attack 
occurred toward the close of 1876, and the seventh (last) seizure was on Feb- 
ruary 9th of the present year (1877), without warning or vomiting. In the 
other attacks the warning sensation was quite prolonged ; on one occasion 
was able to walk nearly a quarter of a mile before falling. 

He has had no petit-mal, and general health has been unimpaired. Has 
done well at college. 

The following letter was sent to me with the patient, and it well illustrates 
the erroneous notions which prevail with respect to the significance of a sin- 
gle epileptic fit, or of fits returning at long intervals. 

New York, February 11, 1S77. 



u . . . . This will be handed you by Mr. D , who has been under 

my care for some time with epilepsy. At first I attributed his attacks to 
gastro-intestinal causes, and rectified all bad habits of life and regimen. The 
disease recurred, and then I put him upon a diet exclusively vegetable 
and interdicted stimulants. He will tell you how he has fared upon this 
plan. . . ." 

It appears that Mr. D was first prescribed for by t)r. X., who is a very 

eminent practitioner and teacher in New York, after the fourth or fifth attack, 
in 1876, when the disease had been going on two years and more. No bro- 
mide of potassium or sodium had been given until within a very short time 
previous to the consultation. 

Though foreign to my present purpose, I might add that a bromide treat- 
ment, consisting in giving only a night dose of from 4. to 5. of bromide of 
potassium, has greatly improved the patient. 

After the consultation some attacks returned, and I find the following 

record, July 16, 1878: Mr. D returned from Germany a few days ago. 

He had had no attack since the beginning of August, 1877. Once in Europe 
had a slight threat of attack, without loss of consciousness. Has led a regular, 
quiet life, and has taken 4. of potassium bromide every night without omission. 
General health excellent. 

August 4, 1879. — No attack since threat in Germany, twenty months ago. 
Takes 4. nocte ; ordered reduce to 3.5. 

October 19th. — Slight attack after an interval of twenty-eight months; fell 
and bit his tongue. Ordered 4. at bed-time. 

December 6th. — No attack. 

September, 1880. — In August, under excitement, felt faint, but this attack 
was not sudden, and he preserved his consciousness. It is now nearly one 
year since last attack. Takes only 2.75 bromide of potassium at night. He 
reduced without advice. 



EARLY RECOGNITION OF EPILEPSY. 545 

October 14th. — Slowly developed attack, without local aura ; felt confused 
before losing consciousness ; had spasm, but did not bite tongue. Ordered 4. 

January 5, 1881. — ±so attack. Through erroneous weighing of bromide, 
has taken only 3. every night. Ordered 4. 

March 23d. — Xo attack. 

Summary. — Since August, 1877, only two epileptic attacks, and one "threat." 
This is a period of now (June, 1881) nearly four years. 

Has finished the study of law, and is in good physical and mental health. 

Case Y. — Ira K., aged eight years, seen February, 1877. Was a healthy 
baby; no convulsions while teething. When two years old fell down a long 
flight of stairs without apparent injury. Remained well. When four years 
of age, fell from a horse, cutting the scalp in the occipital region ; no loss of 
consciousness or vomiting. 

In six or seven months after this injury, about three and a half years ago, 
had a first (?) nocturnal epileptic attack. Until lately has had chiefly nocturnal 
spasms. At first had a few diurnal seizures, and again lately. 

Has had much petit-mal, increasing in frequency — of late almost daily. 
This consists in staring, loss of consciousness, a "hum" or "hem" noise, and 
sometimes slight jerking of the arms and throwing back of body. 

In the last few weeks child has been less bright, and has exhibited a thick 
articulation. 

During the long periods of time the child was treated "for worms" and 
for "disorder of the stomach." 

Case YI. — Mary C , aged sixteen years, seen October, 1879. Born 

healthy and remained well until sixtli year, when, after indulgence in green 
fruit, she had an attack of very severe convulsions lasting two hours ; did not 
bite her tongue, and there was no consequent paralysis. 

This was succeeded by numerous "fainting turns," as the mother calls 
them. In these the child was unconscious, pale, still, with eyes open and 
staring. This was petit-mal; the next attack of grand-mal occurred in two 
years, and afterward the convulsive seizures became frequent, from one or two 
in one day to one in two or three weeks. 

The child had an irregular bromide treatment. 

Since has had three types of attack: petit-mal (rarely now), grand-mal, and 
mixed attacks. One of the last kind was witnessed in my office, and is thus 
described in the case-book: "Makes complaint of aura, asks for amyl, dilata- 
tion of the pupils, pale face, general spasm of semi-tonic kind, muttering, 
raising of clothes, picking or grasping at chair, incoherent remarks, makes 
some swallowing movements, does not bite tongue, or froth ; return to con- 
sciousness." 

The aura referred to is almost always felt ; it consists in a sensation just 
above the umbilicus, not ascending, but feeling as of a " soft whirling " or 
"trembling" sensation in the abdomen; no nausea. 

I mention this case because of the apparent etiology. It may 
have been looked upon as a case of convulsion and vertigo from 
gastric irritations, and treated accordingly. It certainly appears 
35 



546 EARLY RECOGNITION OF EPILEPSY. 

that a serious bromide treatment was not given during the first 
two or three years of the disease. 

Case VII. — Clara C , aged five years, seen April, 1880. In February 

1879, had a first attack of convulsions, on both sides of the body. 

In four weeks experienced a second bilateral attack. In April there re- 
curred an attack in which the spasm was wholly limited to the left side of the 
body, followed by a number of others, all within a period of twelve hours ; 
no consequent paralysis. In the month of May passed through another status 
epilepticus, in which some of the spasms were on the left side, others bilateral. 
The bromide of potassium was then steadily given until June, when the 
mother suspended its use. Had no treatment and remained free from attacks 
until February, 1880, when a status epilepticus of forty-eight hours' duration 
occurred; most of the spasms were bilateral, and a few involved only the left 
arm and leg; never bit her tongue. Early in March several attacks in a 
group. Paralysis has never been observed after attacks, but the child is cross 
and has headache after them. Most of the attacks have been nocturnal. 

Recently one dizzy spell. 

After this consultation, a stricter bromide treatment was attempted, but 
never faithfully carried out by the mother. 

Status epilepticus occurred in June and September, 1880; many attacks 
limited to left side. After June attacks, she was almost maniacal for one 
month. 

From January 21&t to February, 1881 (when last seen), many seizures, most 
of them of mixed type, some like petit-mal; calling out, with slight shaking 
of both arms, staring, and pallor of face. Very unmanageable ; semi-maniacal 
at times in last few weeks. 

Family neurotic ; maternal grandfather subject to violent neuralgias about 
the head (specific ?) ; mother of child had convulsions from eighth year, for 
how long a time and of what kind it is impossible to learn. 

Careful examinations of the child on two occasions, nearly one year apart, 
gave no objective symptoms indicating the existence of what one would 
naturally suspect, viz., a localized lesion (tumor?) in the right hemisphere of 
the brain. 

For many months the physician in charge of the child, and the consulting 
physician, a man of great eminence, ignored the truly epileptic nature of the 
child's attacks, asserted their curability, and treated the child carefully for 
worms and for disorder of the digestive organs. 

Case VIII. — Jas. W , aged twenty-one years, seen October, 1878. 

Health has been good; denies masturbation, sexual excess, and syphilis. 
Married fifteen months ago, and has one healthy child. 

First epileptic attack occurred three years ago, and the second after an 
interval of eighteen months. Since the second attack, has had seizures with 
increasing frequency — thirteen in the last twelve months. Last seizure 
occurred yesterday. The attacks have all been nocturnal, occurring at from 
one to five o'clock a.m., and characterized by severe spasm, biting of the 
tongue, and passing urine in the bed, and followed by heavy sleep. The 
next morning has headache. 

Did not have treatment until after attacks became frequent. 



EARLY RECOGNITION OF EPILEPSY. 547 

This case is interesting, as showing the real significance of a 
first epileptiform seizure in a non-syphilitic and non-urgemic 
adnlt. The patient had epilepsy just as much after the first 
attack as he did when the seizures recurred every two or three 
weeks, and the proper time for successful treatment would have 
been after the first attack. 



Case IX. — Mary L , twenty-two years, seen October, 1880. When only 

three weeks old had a series of convulsions in the course of one week, followed 
by cyanosis. Afterward was subject to "screaming spells,' 1 in which she 
threw her body forcibly backward. 

From fourth to eighth year no attacks of any kind. When eight or nine 
years of age had attacks of unconsciousness, in which the eyes rolled up, the 
appearance was statue-like, with a cataleptic state of the limbs. These 
attacks have occurred daily since ; on some days she has had as many as ten 
or twenty seizures. 

Menstruation occurred at thirteen years, but the attacks continued un- 
changed. Went to school at usual age, but study was abandoned in twelfth 
year, nominally because of "indigestion,*' but in reality because patient's 
mind was feeble; she was to a degree imbecile. 

In the last fourteen months has had five attacks of grand-mal; the first in 
August, 1879, the last one about two weeks ago. In these severe attacks she 
did not bite her tongue. Has had fewer attacks of petit-mal since these 
convulsions. 

Patient states that she has no aura; as to frequency of petit-mal, she thinks 
she may have had as many as one hundred " spells " in one day. 

The existence of neuroses in the family is denied. The cause of the second 
series of epileptic phenomena (from eighth year) appears to have been mas- 
turbation, which was practiced from the sixth or seventh year until some time 
after attacks set in. Positively denies self -abuse in the last few years. 

This young woman's father was a physician, recently deceased, but the 
epileptic, nature of the disease was not recognized until the convulsive attacks 
of 1879-80. 

Case X. — Mrs. C. A. R., aged twenty-eight years, seen December. 1878. 
Was a robust, healthy girl; menstruated in her thirteenth year. In the 
same year had a very severe attack of typhoid fever, followed by great 
debility of body and mind. Sexual feeling, which had already been ex- 
perienced by the patient, disappeared and has never returned. Menses 
continued nearly regular. At an uncertain time (not long) after the fever, 
began to have petit-mal of the faintest kind; a mere momentary blurring or 
loss of consciousness, at frequent, but irregular intervals. 

Married at eighteen, and has borne children. Petit-mal has continued 
occasionally. At about twenty-one had a first convulsion one morning after 
rising; she frothed at the mouth and bit her tongue. In about two months 
had a second equally severe attack, and a third one thirteen months later. 
Then was given bromide and valerian, but irregularly. Four years passed 



548 EARLY RECOGNITION OF EPILEPSY. 

without any convulsions, but she continued having petit-mal at intervals of 
a few days to three weeks in length. 

In 18T6 was in Europe travelling, not eating much and using stimulants ; 
had an attack in the summer (grand-mal), and three since. The last one 
occurred six weeks ago, in the night. Petit-mal occasionally. 

In reality this patient was ejDileptic some twelve years without having a 
proper diagnosis and treatment. 

Case XI. — Lizzie B., aged twenty-seven years; seen July, 1880. Since the 
age of eleven or twelve years has had peculiar attacks, consistiug of a sensa- 
tion of something starting in the epigastrium and rolling up to the throat, 
lasting only a few seconds, not accompanied by tears or other .emotional dis- 
turbance. Thinks that her consciousness is not lost; calls for hartshorn. At 
first these attacks occurred once in three or six months ; in the last year has 
had them every two or three weeks. The true nature of these attacks was 
ignored, though patient was under the constant supervision of a good phy- 
sician. 

Menstruation established at fourteen years (long after first petit-mal) ; ir- 
regular and with pain. 

In March, 1880, patient had a regular convulsion, and a slighter one a few 
days ago. These attacks are described by patient's sister ; she herself thinks 
that they were "long faints." [This shows how much reliance is to be 
placed on her other statement that she preserves her consciousness in the 
slighter seizures.] 

It was only after the spasm in March that a bromide treatment was insti- 
tuted. Patient went home in October. 

Since January, 1881, quite a number of attacks of grand-mal. 

Case XII. — Dr. 's son, aged twenty-two years, Xovember, 1880. 

Patient not seen ; statement made by the father. 

From twelfth to sixteenth year had occasional "frightened spells" or 
" faint spells." Xo details. 

In sixteenth year first recognized epileptic attacks ; usually nocturnal ; grand- 
mal at intervals of one or two months. Four attacks in the last four months. 
In attack spasm begins on the left side of the body, and is most severe on 
that side; the tongue is bitten, and there is frothing at the mouth. 

In 1878-79 had no grand-mal (interval of nearly two years). 

At age of six or seven years fell on the ice, striking on his forehead; lost 
consciousness and vomited. 

Masturbation begun in eighth year, probably before petit-mal, which it 
appears began before the twelfth year, as stated in commencement of the 
history. 

The father, though a practicing physician, paid no special attention to the 
petit-mal, and attributed the first convulsions to late suppers and gastric irri- 
tation in general. 

The foregoing cases indicate that the error usually committed 
in judging of the true nature of first epileptic seizures is in con- 
sidering them to be sympathetic convulsions, due to remediable 
causes — in other words, eclamptic attacks. 



early recognition of epilepsy. 549 

This capital diagnostic error is founded upon two erroneous 
conceptions, in mv opinion : 

1. A physiological misconception. In the first two years of 
life there is great convulsibility ; the spinal axis is excessively 
irritable, and many causes, local, diathetic, and thermal, may 
produce convulsions. Thus, pneumonia, exanthemata, infantile 
spinal paralysis, intestinal worms, gastric irritation, gingivitis, 
sexual irritation, etc., may cause convulsive attacks, which are 
usually called eclamptic. If the cause be removed, such attacks 
do not recur. In the third and fourth years of life, more or less 
rapidly according to the constitution of the child, this mobile 
state of the spinal axis diminishes, the inhibitory cerebral influ- 
ence is more and more shown, and the tendency to reflex spas- 
modic manifestations almost disappears. 

The misconception lies in admitting, beyond the truly infantile 
age (three to four years \ a liability to symptomatic or eclamptic 
convulsions. 

There are' excejDtions of course — some few children, and even 
adults (especially females), show convulsibility ; but I believe 
that it may be stated, as a law most useful in estimating the 
significance of a first fit, that after the third or fourth year 
eclamptic attacks (except from uraemia) are excessively rare. A 
first rule for the study of convulsions then is, that convulsibility 
diminishes rapidly after the third year. 

2. An etiological misconception, consisting in over-estimating 
the exciting powers of local, internal, and peripheral causes. 
Tbe doctrine of reflex neuroses, reflex neuralgia, reflex spasms, 
reflex paralyses, and of reflex psychoses, has fallen from the very 
high standing it acquired, mainly under the influence of Brown- 
Srcjuard, some fifteen or twenty years ago. Reflex diseases of 
all kinds are now rarely reported by reliable observers, and 
more especially is this true of paralysis. That there are reflex 
nervous diseases I recognize, but I claim that they are not by 
any means as common as is usually believed. 

]\Iore especially would I maintain this with respect to con- 
vulsions occurring after the third year of life. Cases of convul- 
sions, or epilepsy, in individuals above three years of age, due 
to cuts, blows, worms, adherent prepuce, etc., abound in older 
medical writings, books, and journals ; but in the last ten years 
physicians have become much more guarded, and such cases, 
when reported, are considered very interesting because of their 



550 EARLY RECOGNITION OF EPILEPSY. 

rarity. Leaving out injuries about the head, I am not sure that 
I have met with such a case. 

I would suggest, as a second safe rule in studying first con- 
vulsions, that after the third year of life, local irritations, inter- 
nal or external, are not likely to cause convulsions without the 
pre-existence of a morbid state of the nervous centres, inherited 
or acquired. 

The terms eclamptic and epileptic, as applied to convulsions 
accompanied by loss of consciousness, have been the source of 
great confusion. The words are often used as if they designated 
different symptom groups, whereas, in reality, as sanctioned by 
observations and by the best authorities in our art, they mean 
the same symptom group, occurring under different conditions. 

I might support this statement by numerous citations, and by 
a minute description of a variety of attacks of each kind ; but 
my time is short, and I will content myself with giving the opin- 
ion of a few authorities. 

In the first place, Professor Trousseau says : * 

" I have often known epilepsy and eclampsia to be confounded 
one with another, and I have also said that this confusion is 
almost inevitable, because, if we study only the convulsive mani- 
festations of these two affections, they are indistinguishable. 

"If you observe a woman attacked with eclampsia in the 
eighth or ninth month of pregnancy, or during confinement, or a 
child who is convulsed, either at the beginning of an eruptive 
fever or during dentition, however you may be on your guard — 
however careful you may be in your observations — you cannot 
make out any [symptomatic] differences between these attacks 
and the convulsive form of morbus caducus." 

Dr. Day, in the recent edition of his excellent work on diseases 
of children,t quotes with approval Trousseau's statement as to 
the similarity of eclamptic and epileptic attacks — the latter 
being the former repeated in a series — and adds, when speaking 
of eclamptic attacks : 

"In many respects they (the convulsions) resemble epilepsy, 
from which, indeed, they cannot invariably be distinguished." 

An encyclopedic treatise on diseases of children is being issued 



* Clinique Medicale de l'Hotel-Dieu de Paris. Seconde edition, vol. Hi., p. 88 
Paris, I860. 
\ The Diseases of Children, p. 607, American edition. Philadelphia, 1881. 



EARLY RECOGNITION OF EPILEPSY. 551 

in parts, in Germany, and the opinions of its numerous authors, 
all men of high standing, will be received with respect. * 

Dr. Otto Soltmann, of Breslau, in treating of epilepsy, says 
(p. 103; : 

" The eclamptic attack cannot be distinguished by its symptoms 
from the epileptic attack." 

Nothnagel, an authority upon the subject of epilepsy, writes 
as follows of eclampsia, in Ziemssen's Cyclopaedia : t 

" What is there now remaining of what was formerly recog- 
nized as eclampsia ? Are we altogether justified in still retain- 
ing the name ? We believe so, and are of opinion that the title 
of eclampsia should be reserved as the name of an independent 
affection, which, it is true, can at present be denned only by 
its clinical symptoms. We propose that the designation eclamp- 
sia should be made use of for those cases of epileptiform spasms 
which — independently of positive organic diseases — present 
themselves as an independent acute malady, and in which, so far 
as our present knowledge allows us to judge, the same processes 
arise, generally in the way of reflex excitement, and the same 
mechanism in the establishment of the paroxysms comes into 
play, as in the epileptic seizure itself. In this way, as we see, 
the designation <f eclampsia as an acute epttepsy finds greater authori- 
sation [the italics are my own] ; at the same time it is distin- 
guished from true epilepsy by the lack of a persistent central 
change, which latter impresses upon epilepsy the character of a 
chronic condition. In the case of eclampsia, where this chronic 
change is absent, the manifestations, the seizures, disappear with 
the removal of the exciting irritation." 

We may sum up these statements of high authorities by saying 
that eclamjitic and epileptic attacks are similar in character and 
practically indistinguishable. 

This being admitted as being true of the symptoms, we yet 
have the two affections, eclampsia and epilepsy, to* differentiate ; 
and it is this differentiation or differential diagnosis which is 
all-important for the welfare of our patient. It is not so very 
serious to consider eclampsia as epilepsy for a few months ; 



* Handbuch der Kinderkrankheiten : Herausgegeben von Dr. C. Gerhardt. 
Bd. v., Abth. i. lste Hiilfte : Krankheiten des Nerven- systems. Tubingen, 
1879-80. 

f Cyclopaedia of the Practice of Xedicine. Edited by Prof. H. von Ziemssen. 
American edition. Article on Eclampsia, vol. xiv., pp. 301-2. 



552 FAULT RECOGNITION OF EPILEPSY. 

but the converse mistake— the one illustrated by the cases I 
have read, the mistake which I believe is common, is in one 
sense fatal to the patient. The non-recognition of epilepsy 
allows of recurrence of paroxysms and the establishment of the 
epileptic habit. 

Upon what grounds can a reasonably accurate diagnosis be 
made ? I believe this can generally be done by attention to the 
physiological law of convulsibility, and to the relatively small 
importance of local irritations, internal and external, after the 
third year of life, as a cause of eclampsia. These two points 
have already been referred to at some length. A third rule which 
must be borne in mind is, that at almost any period of life uraemia 
may cause eclampsia. This is more especially true of young 
subjects who have just passed through scarlatina with nephritis, 
or who have had symptoms of renal disease from any cause ; and 
also of adults — males between thirty-five and fifty — who are 
liable to contraction of the kidneys. 

A fourth diagnostic rule is that, in adults particularly, syphilis 
may cause eclampsia {i.e., acute, curable epilepsy). 

Plumbism and alcoholism sometimes cause eclampsia, but 
probably in most cases by producing renal changes and uraemia. 

To apply these principles to practice, let us suppose cases of 
first convulsions with loss of consciousness, occurring in subjects 
of various ages. 

1. Convulsive attacks in young children under three years. 

If we can exclude injury to the head, gross organic disease of 
the brain, and microcephaly from premature closure of the 
fontanelles, the attack is probably eclamptic. This probability 
is increased to almost a certainty if we can accurately determine 
the existence of sufficient systemic or local causes for the attack. 

Upon this question of sufficiency of the cause, much might be 
said. Often the physician is satisfied with merely determining 
the coincidence of a fit with a local irritation, or a supposed 
local irritation. Soltmann * is especially emphatic in his advice 
to judge these coexistent conditions carefully before pronouncing 
them to be causes and the attacks to be merely eclamptic. 

The occurrence of a single fit enhances the probability of its 
being the first seizure of epilepsy. 

The occurrence of repeated attacks in the course of an hour 
or two makes it probable that the convulsions are caused by 

* L. c, pp. 49-54. 



EARLY RECOGNITION OF EPILEPSY. 553 

fever, by gingival, gastric, or intestinal irritation, or perhaps by 
some peripheral cause. 

2. Convulsions in young persons from three to fifteen years 
of age. 

These are quite certainly epileptic, if we can exclude renal 
disease. The occurrence of attacks of an eclamptic nature {i.e., 
ephemeral and curable) in such subjects from intestinal, or gas- 
tric, or sexual irritation, is exceedingly rare, and the mistake 
— the terrible mistake — of assuming such to be the pathology 
of convulsions, is frequently made, even by experienced physi- 
cians. 

I would repeat, and the foregoing cases bear me out, that 
convulsions from worms, from indigestion, from litha?mia, or 
oxaluria, in youth are exceedingly rare, and that in the treatment 
of such a case the patient should be given the benefit of the 
doubt and be put upon a rigid anti-epileptic treatment by means 
of bromides, while the treatment for the supposed local or 
diathetic cause is being carried out. 

3. Convulsions in adolescents and adults. 

These are to be judged by the same general rules as No. 2, 
with the addition that two morbid conditions should be carefully 
searched for, especially when the first convulsion occurs after 
twenty. 

a. Syphilis. This may be acquired at almost any age, but 
especially after sixteen or eighteen years. Nothing in the social 
standing of the patient should deter the physician from inquir- 
ing delicately, yet deeply, into this question. 

b. Chronic interstitial nephritis, more particularly in subjects 
of forty years and upward. The presence of a hard pulse, of 
over-action and hypertrophy of the heart, the passage of an 
excessive amount of urine of low specific gravity, sometimes 
containing albumen (never much), and a few hyaline or granular 
casts — these symptoms go to justify the diagnosis of contracted 
kidneys, consequent chronic uraemia, and the occurrence of 
eclamptic attacks. 

If we exclude these two pathological conditions, a convulsion 
in an adult, especially if a single fit, is quite certainly epileptic, 
and will be followed by others, after a lapse of time which may 
vary from a few days to more than a year. Of course the exist- 
ence of a long interval of health after one epileptic attack in no 
wise justifies . a physician in pronouncing the disease not to be 



554 EARLY RECOGNITION OF EPILEPSY. 

epilepsy, as is shown by some of the cases I have read, and 
by numerous others which I might cite. 

To sum up the early diagnosis of convulsions : 

1. After the third year such attacks are very probably epilep- 
tic. The possibility of uraemia and of syphilis should be borne 
in mind, and a careful investigation be made as to their exist- 
ence. 

2. Under the third year the attack may be eclamptic — probably 
is — but its causes should be carefully judged. 

3. In many cases under three years it is well to give a 
moderate amount of bromide of potassium (or sodium) with 
regularity for several months after a convulsion, that is to say, 
in such cases as do not present an evident, indisputable patho- 
logical condition sufficient to cause eclampsia. 

4. In all cases above three years the bromide treatment should 
be at once instituted and kept up for many months. 

This will not interfere with the treatment by appropriate 
remedies and by hygiene of gastric or intestinal indigestion, of 
worms, of sexual irritation, of uraemia, and of syphilis. 

Besides bromides, a variety of treatment is demanded by 
different forms of epilepsy, according to the pathological con- 
dition ; but the consideration of these indications is foreign to 
this paper, whose main object is to encourage the prompt and 
proper treatment of epilepsy at the earliest possible moment, 
viz., in most cases after the first attack. 

I am confident that, if this were done, the prognosis of con- 
vulsive epilepsy would be greatly changed for the better. 

I now pass to the consideration of the diagnosis of petit-mal, 
consisting of epileptic vertigo (so called), and of imperfect or 
aborted spasmodic seizures. 

In this category I do not include the localized or hemiplegic 
epileptic spasms, which I have treated of in a former paper. 

Petit-mal, or epileptic vertigo, is often allowed to pass for 
vertigo eaused by indigestion. In my experience, physicians 
are very loath to call these slight attacks by the terrible name of 
epilepsy, and so delude themselves and their patients until the 
recurrence of a convulsive attack settles the question. 

Besides, I find that, even when the attacks are recognized as 
epileptic, a most unfortunate statement is made that these are 
slight and manageable attacks, whereas the truth is that petit- 



EARLY RECOGNITION OF EPILEPSY. 555 

mal is much more intractable than grand-mal, and often leads to 
more evident mental deterioration. 

The correct diagnosis of petit-mal is feasible, provided a good 
description of the seizures be had. 

From vertigo it is distinguished by : 

1. The subjective phenomena. In vertigo there occurs a 
sensation as if the patient himself or objects about him were 
whirling around ; in petit-mal there is no such feeling, but a 
sensation of confusion, or of something rising from the throat or 
epigastrium to the head. In some cases there are no sensations 
in the head beyond the consciousness that something is wrong 
for a moment. 

The sensations of petit-mal are, moreover, usually sudden, or 
even flash-like, whereas in vertigo, cardiac syncope, and some 
hysterical attacks, there elapses quite a time in which the attack 
is growing. This suddenness of onset is very characteristic of 
minor epilepsy. 

2. By objective phenomena. In faints and in some hysterical 
states the patient is limp from the start, and in other hysterical 
attacks there is spasm lasting many minutes. In petit-mal there 
is nearly always spasm, but not as in grand-mal. It usually ex- 
presses itself by a momentary rigidity of the whole body, with 
staring eyes and wide pupils. To express it otherwise, there is 
for an instant an unnatural immobility — the patient is, as it 
were, petrified for a few seconds. The friends of patients will 
usually accept the suggestion that the patient is statue-like in 
the attack. 

It is to be borne in mind that in some cases the patient keeps 
his equilibrium, or even continues to walk. Nearly always, 
however, the action which the patient was doing at the moment 
(eating, talking, walking) is impeded or interrupted, to be re- 
sumed naturally after a few moments. 

Some of these attacks of petit-mal are literally like a flash — 
just a moment's obscuration of consciousness. The conscious- 
ness is wholly lost in the various forms of petit-mal, though 
many patients* will claim the contrary. The truth is usually 
easy to learn from the patient, or friends of the patient, and is 
at once evident if you happen to witness a paroxysm. I am in 
the habit of not relying upon an epileptic's statement that he is 
conscious during an attack, without suflicient corroborative tes- 
timonv. 



556 EARLY RECOGNITION OF EPILEPSY. 

The dilatation of the pupils and their immobility, and the 
open state of the eyes, are capital symptoms. 

In syncope and hysteria the eyes are closed and the muscles 
limber. The lids in hysterical "faints" present an almost 
pathognomonic appearance ; they are rather tightly closed, and 
present vibrations or quivering motions due to the prolonged 
effort at closure. In neither of these conditions is the pupil 
fixed and widely dilated, as in epilepsy; this is a symptom 
which cannot be imitated. 

Vertigo from gastric disorder is characterized by a sense of 
whirling in the head, and often a sensation as if the ground were 
opening in front of the patient, or falling away from before him, 
with impending precipitation. The observer notices no dilata- 
tion of the pupils, or staring, or momentary stiffness of body ; 
the patient can speak at any time. In severe cases the vertigo 
is very frequent and is produced by the least motion. 

I cannot enter fully into a description, for diagnostic purposes, 
of each and every variety of petit-mal. This would take a long 
time. 

Allow me to refer to the intermediate attacks, in which there 
is some jerking of one of the limbs, or in which the patient says 
or does something odd. In some cases the patient will rise 
suddenly from a chair, walk rapidly about, muttering something. 
In other cases the patient will lie back in his chair with the 
epileptic facies, and jerk both arms or the limbs on one side of 
the body for a few moments. In other cases, the patient being 
out of doors walking in the street, loses himself for a few blocks, 
and is surprised at his change of location. In other cases there 
may be incoherent or semi-coherent talking. Other patients 
simply stare and make swallowing movements, with or without 
dreuling. Other patients fumble and fuss about with their 
hands, while staring and unconscious. 

The unconsciousness and the attendant pupillary phenomena 
are the chief diagnostic symptoms in these cases ; but a very 
important element in the differential diagnosis between these 
attacks and hysterical ones is that the latter present variations 
each time, whereas the mixed epileptic seizure is almost a 
stereotyped performance, one or two sets of movements being 
done by the unconscious subject. 

Still other cases of non-spasmodic epilepsy occur in the shape 
of periodic or paroxysmal attacks of mania or melancholia. In 



EARLY RECOGNITION OF EPILEPSY. 557 

some of these cases the careful observer finds that a nocturnal 
fit or an unobserved diurnal paroxysm ushers in the psychosis ; 
but in other cases the mental disorder appears in a periodic 
epileptoid manner, and convulsions or petit-mal make their ap- 
pearance later on. 

I have already given it as my opinion, or rather as the sum- 
mary of my experience, that petit-mal is often ignored for years, 
and is usually looked upon as a trivial affection. 

It is my present purpose to urge the early recognition and 
careful treatment of this seemingly insignificant symptom. It 
appears to parents, and too often to physicians, as infinitely less 
serious than grand-mal or " fits ; " yet I can assure you that the 
contrary is true. 

Petit-mal, especially the flash-like form, is exceedingly rebell- 
ious to treatment. I have now several little patients who con- 
tinue to have several " turns " a day, despite the use of as much 
bromide, etc., as their systems will bear. I have repeatedly had 
to produce severe bromism in order to barely control these 
minor forms of epilepsy, and any reduction of the medicine to a 
safer dose was followed by a return of symptoms. In taking 
charge of a patient who has such petit-mal I always explain to 
the parents or relatives the difficulty of the task they have 
brought to me. In my experience, spasmodic attacks — even the 
most severe fits — can nearly always be controlled by a proper 
dosing of the bromides — they may also be suspended for months 
and years ; but we have little control of the minor manifesta- 
tions of the disease. 

Still, in all forms of epilepsy the date of its recognition as 
epilepsy is an all-important factor in prognosis. By repeated 
seizures a condition of the nervous system (epileptic centre ?) 
becomes established, which we designate as the epileptic habit, 
a condition which explains the remarkable fact that in some 
cases of symptomatic or reflex epilepsy the attacks continue 
after removal by surgical means of the morbid focus whence the 
attacks seemed to be produced. 

By instituting treatment very early, if possible after the first 
or second attack, we eliminate this factor, and the chances of 
cure are greatly increased. 



ON THE METHODS OF DIAGNOSIS IN DISEASES OF 
THE NERVOUS SYSTEM.* 



Lecture I. 

Gentlemen : — I propose to devote this and a subsequent lec- 
ture to a brief summary of the methods of diagnosis, more par- 
ticularly those resorted to in organic nervous diseases, describing 
the instruments used and showing you how to go over a patient's 
body and examine it. A knowledge of the methods of diagnosis 
and of how much trustworthy information they will yield us is 
very important, and, I think, may be considered with profit. I 
will have a patient brought in, that I may make such manipula- 
tions upon him as are used in forming a diagnosis. Of the 
functions of the nervous system there are two general divisions : 
in the first place, the functions of movement ; and in the second 
place, the functions of sensibility. An examination into the 
psychic functions is of greater importance, but hardly a subject 
for a clinical discourse. 

For determining the condition of the functions of movement 
there are three methods, viz.: 

1st. By means of dynamometers. 

2d. By the performance of passive and active movements. 

3d. By inspection. 

1. The instrument which is mostly used in making examina- 




*fi£ VHO£R J Ca 

Fig. 1. 

tions into disorders of movement is the dynamometer, or strength- 
measuring instrument (see Fig. 1). There are several varieties 
of dynamometers. The one I use is the simplest kind, and 

* Prom the New York Medical Record, Dec. 3d and 24th, 1881, and The Medical 
Press and Circular, Oct. 4th, 11th and 18th, 1882. 



METHODS OF DIAGNOSIS. 559 

consists of an elliptical steel spring which can be compressed 
in the hand or other parts of the body. Connected with it is a 
cog-wheel, which moves an index needle upon a dial, the index 
needle remaining where it is carried by the muscular effort of 
the patient. The French instrument is provided with a double 
scale, which I think is altogether unnecessary. Observations 
made with this dynamometer, when recorded, should be accom- 
panied with a statement as to whether the numbers refer to the 
inner scale or outer scale, as the numbers indicated on the two 
scales differ enormously. For instance, the dynamometer 
needle in this patient's grasp points to 200 on the outer scale, 
and 70 on the inner scale. These numbers are supposed to 
represent kilogrammes, but I have no faith in the accuracy of 
such representations. Again, there is no advantage to be 
gained by knowing the exact number of kilogrammes of force 
exerted. A registration of degrees of force is entirely sufficient, 
and I always speak of the numbers indicated in any particu- 
lar case as so many degrees. Now, as to the method of 
grasping the instrument. It should be grasped fairly and 
squarely in the hand, with the second phalanges resting upon 
the spring, and should be compressed without resting the hand 
or arm upon anything, and without giving the arm a swing at 
the moment of compression, as some patients will do. It is also 
important to place the face of the dial toward the palm of the 
hand, otherwise the fingers of the patient may interfere with the 
movement of the index needle. We know that there is in most 
healthy individuals a difference in strength between the left and 
right hands, but we want to estimate it. There are very few 
healthy individuals with a difference of more than five or eight 
degrees ; a difference of ten degrees would lead to the suspicion 
of paralytic weakness upon one side. Sometimes we find the 
left hand stronger than the right. A number of patients are 
left-handed, and therefore use the left hand more than the right. 
There are some occupations which tend to develop more 
strength in the left hand than in the right. Car drivers show 
equal strength of both hands, or greater strength with the left 
hand, for the reason that the reins are held in it. I need not go 
into further details, but will say that you should be on the 
look-out for these normal variations in making tests with the 
dynamometer. 

My friend, Dr. Birdsall, has invented a foot dynamometer, 



560 



METHODS OF DIAGNOSIS. 



which is intended to record the comparative degrees of strength 
of either the anterior or posterior tibial group of muscles upon 
the two sides of the body. It consists (see Fig. 2) of a board 
with a movable foot-piece, which is grooved so as to receive the 
hand dynamometer between the base-board and the movable 
foot-board. The foot-board is provided with a toe and heel 
strap, by means of which the foot is secured in position upon it. 
By placing the hand dynamometer in the front grooves and 
strapping the heel down upon the foot-board, and telling the 
patient to lift his heel, the strength of the posterior leg-muscles 
can be approximately estimated. For testing the anterior tibial 
group of muscles the ends of the instrument are reversed, the 
hand dynamometer being left in position, and the toes strapped 
to the foot-board. The patient is then directed to attempt 
to raise his toes, and in so doing the power expended 
is transmitted through the heel to the hand dynamometer. 
This instrument was brought to the notice of the profession by 
Dr. Birdsall, in a paper read before the American Neurological 
Association. Its accuracy is not as great as that of the hand 
dynamometer, but, as I have already remarked, we do not care 
so much for an accurate record of the force expended as we do 




Fig. 2. 



for a comparative measurement of the force exerted on the two 
sides of the body. 

There are registering dynamometers which record upon paper, 
or other prepared material, the muscular strength and tone of 
the patient. There are also dynamometers which will register 



METHODS OF DIAGNOSIS. 561 

the amount of pulling or pushing force exerted, and so on ; but, 
for practical work, all that is necessary is a good hand dyna- 
mometer. 

2. Another method of detecting disorders of movement is by 
handling the patient. The manipulations are made with our 
hands, and against the patient's will. We are thus enabled to 
determine the amount of resistance — strength of a great many 
muscular groups in the body. We lay hold of the patient's 
limb, having directed him to hold it in a given position, and tell 
him to resist our efforts at flexion or extension. By having the 
patient resist downward pressure upon the chin, wo can deter- 
mine whether there be paralysis of the masseters, temporals, or 
pterygoids. If paralysis exist, a very slight downward pressure 
will be sufficient to overcome the muscular resistance, and thus 
open the mouth. We can judge of the condition of the neck- 
muscles by the movements of the head. We direct the patient 
to hold his head perfectly stiff and upright, and see how much 
force is required to move it forward or backward. In a similar 
way we test the power of the flexors and the extensors of the 
arm. In partial lead-paralysis only a very slight force is re- 
quired to flex the hand. The short flexors of the hand can be 
tested in this way, and even the interossei can be tested by 
lateral movements of the fingers. With the lower extremities 
we proceed in a corresponding way. To test the quadriceps ex- 
tensor femoris, we make the patient hold the leg in extension 
and attempt to flex it. For testing the posterior thigh muscles 
we cause the patient to flex the leg upon the thigh, and take hold 
of the foot and pull it forward. The same test which was 
applied to the hands and fingers can be applied to the foot and 
toes. The abductors and adductors should be tested in the same 
way. In little children under three years the condition of the 
muscles may be examined by wMat I am in the habit of calling 
the cataleptoid test ; or, more properly speaking, we note the 
absence or presence of the cataleptoid state in the muscles. I 
have found that if we divert the attention of a healthy baby and 
gently place one of its arms or legs in a given position, or in any 
position, that position will be maintained for several seconds or 
minutes. The limb is held by an automatic muscular contrac- 
tion — an exaggeration of the muscular tonus. This normal state 
I call the cataleptoid state. In paresis or paralysis, more espe- 
cially in infantile spinal paralysis, the affected limb, when most 
36 



562 METHODS OF DIAGNOSIS. 

carefully placed as described above, falls at once, like lead, in 
obedience with gravity. 

The ocular muscles can be tested by requesting the patient to 
follow an object about with his eyes without moving his head. 
Convergent and lateral movements can thus be studied. A good 
way of testing the interni is to hold your finger at about twelve 
inches from and in front of the patient's eyes, and move it gradu- 
ally to within three inches. If affected, one eye or both eyes 
will diverge. "We test the external recti muscles by making the 
patient follow an object in the outer fields of vision. It must 
not be assumed in obscure cases that this test is sufficient. 
There are cases of diplopia which are not revealed by this means. 
The method by which the oculists determine the existence of 
latent diplopia is to hold a strip of colored glass before one eye 
so as to color one of the images of the object, and thus enable 
the patient to distinguish them. Prisms are also used for de- 
tecting slight weakness of the recti muscles ; but, as this is a 
part of a delicate manipulation of special eye practice, I need 
not more than refer to it. 

3. The third method is by observing the patient's movements, 
or by inspection. The tongue is tested by requesting the patient 
to protrude it, and observing whether it deviates to the right or 
left, and how far it is protruded. You should guard against 
error in making the projection test. If the patient has lost a 
good many teeth upon one side, the tongue may be deviated in 
consequence, or it may be turned out of line by a cicatrix in 
itself. The tongue may be deviated by paralysis of one cheek. 
These sources of error are of considerable importance in a prac- 
tical way. Facial paralysis on one side is evidenced by a draw- 
ing of the features to the opposite side, as well as by loss of ex- 
pression on the affected side. In paralysis of the orbicularis 
palpebrarum the eye cannot "to closed, etc. The various move- 
ments of the arm are to be tried in a systematic way. In evi- 
dent paralysis, of course, we do not make these tests, but in 
slight cases we tell the patient to move both arms simultaneously, 
and note which one moves slower and less forcibly. I will show 
you a case of ordinary hemiplegia. I ask the patient to hold 
up both arms, but you see that the paralyzed arm does not go 
up like the other. 

By voluntary movements we test the various forms of inco- 
ordination. We test co-ordination by testing the precision of 



METHODS OF DIAGNOSIS. 563 

the movements of the muscles, not their strength. A ready 
means of doing this for the arm is to request the patient to shut 
his eyes and try to put the tip of his forefinger upon the end 
of his nose. Some patients cannot do this. In that form of 
sclerosis known as disseminated cerebro-spinal sclerosis, and in 
posterior spinal sclerosis involving the cervical cord, the patient, 
upon being submitted to the above test, has oscillating move- 
ments of the arm and finger, and ends by thrusting his finger 
into his eyes or mouth. Similar oscillations are shown when 
the patient attempts to put a key in a key-hole. These resemble 
closely the movements of a person trying to do the same thing 
while in a state of acute alcoholic intoxication. 

The movements of the legs and feet in walking have been the 
subject of much stud}-. Some observers have endeavored to 
record the peculiarities of gait by means of giant sheets of 
papers so prepared that when a patient walks upon them imprints 
of his footsteps will be left. Such tests require considerable 
expenditure of time, and hence I would ask you to learn to judge 
of the gait of a patient by inspection and by the sense of hearing. 

In the hemiplegic gaifc the foot is turned in, the heel raised, 
and the patient brings the extremity forward with a swinging, 
semicircular movement ; he cannot bend the knee properly. 
This is what the French call the sickle walk. As the foot is 
brought forward, the outer portion of the sole of the shoe 
scrapes upon the floor. Hence it is that these patients first 
wear out the soles of their shoes upon the outer side. As a 
part of the hemiplegic gait should be noted the drooping 
shoulder of the affected side. 

A characteristic walk is the ataxic. In this the leg is well 
raised, and the patient overdoes the extension and abduction 
movements of the step, bringing the foot down, heel first, in a. 
jerking manner. A good method of testing co-ordination of the 
legs is by driving a pin into the toe of the patient's boot, and 
requesting him, while seated, to approximate the head of that 
pin to the head of another which you hold above it. If there 
be ataxia, the foot will oscillate in this movement, as the finger 
does in the nose test. In the recumbent posture there is a more 
classical test of ataxia. Covering the patient's eyes, we bid him 
put his right heel upon his left patella. If he be ataxic, the 
heel wanders about in a vain attempt to hit the mark. 

Another peculiar walk, which is of considerable frequency, is 



564 METHODS OF DIAGNOSIS. 

the paraplegic, tlie walk of partial paralysis. In chronic trans- 
verse myelitis the patient walks with a scuffling movement, drag- 
ging his toes upon the floor. 

By closing your eyes and listening to the walk of two patients, 
one ataxic and the other paraplegic, you can tell them apart 
pasily. The former makes a loud stamping sound with his 
heels ; the latter scrapes the floor with his feet. 

An important walk is the tetanoid, which I first described in 
1873.* The patient takes very small steps and turns the toes 
inward. The feet are approximated, and there is a tendency 
to crossing of the legs from overaction of the adductors. The 
legs are rigid and the feet drag. You will find this in many 
children, occasionally in admits. This walk is believed to indi- 
cate primary or secondary sclerosis of the lateral columns, or 
want of development of the same parts. 

In hysterical hemiplegia the walk is peculiar. A woman may 
seem to have complete paralysis of the arm and partial paralysis 
of one leg. In walking she moves the leg in the proper vertical 
line ; there is no sickle movement ; the foot is carried carefully 
and squarely over the ground, and is dragged. Dr. E. B. Todd,t 
of London, who was one of the most acute and skilful students 
of nervous diseases thirty years ago, first described this walk. 

The walk of patients with cerebellar disease is usually badly 
denominated in the books. It is spoken of as ataxic, but there 
is nothing ataxic about it. If you were to test a patient with 
cerebellar disease as you would one with ataxia, by requesting 
him to shut his eyes and put the end of his forefinger upon the 
end of his nose, etc., he would have no difficulty in doing it. 
The walk of cerebellar disease is inco-ordinate, though not ataxic. 
It is more like the inco-ordination of intoxication, or, as the 
French writers call it, titubating. The patient tries to extend his 
base of support by separating his feet, and his body oscillates 
from side to side. If the feet be bare, the patient's toes will be 
seen working abnormally, and apparently digging into the carpet. 
NothnagebJ: has written the best account of the cerebellar walk. 

I will add a few words about reflexes. These are tested usu- 

* " Description of a Peculiar Paraplegiform Affection." Seep. 127. Also Archives 
of Scientific and Practical Medicine, Xo. 2. Xew York, Februarv. 1873, vol. i., 
p. 101. 

\ " Clinical Lectures on Paralysis," etc. London, 1856. p. 257. 

X " Topische Diagnostik der Gehirn-Krankheiten." Berlin, 1879, pp. 59-51. 



METHODS OF DIAGNOSIS. 565 

ally by pinching, burning, or tickling the soles of the feet and 
other parts of the body. The tendinous reflexes are of more 
recent discovery. "We determine their existence or non-exist- 
ence by tapping upon the tendons with the finger, as in percus- 
sion. Then, there are internal or visceral reflexes, such as those 
of the bladder resulting from the organ being filled with urine, 
those of the pharynx, and so on. In most of our examinations 
we test the tendinous reflexes. The tendon reflex can be tested 
anywhere that a tendon can be got at. Upon the leg you can 
tap the tendo Achillis. The most commonly used and most con- 
venient place of testing the tendon reflex is at the knee. If we 
tap upon the hamstring tendons we get a movement backward. 
The tendon of the quadriceps extensor femoris, or ligamentum 
patellae is always an object of investigation, and striking it 
causes a partial extension of the leg. In certain spinal diseases 
no reflex movement is there present ; in other conditions of the 
cord there is increased reflex at the knee. The best way of 
judging this is to use at first a minimum amount of force in tap- 
ping the tendon, increasing it as necessary to develop the reflex 
movement. Dr. Gray, of Brooklyn, made some interesting ex- 
periments three years ago upon some of the students of the 
Long Island Hospital Medical College as to the normal tendon- 
reflex at the knee. He found it absent in two or three individu- 
als out of a hundred healthy subjects ; and I have seen similar 
exceptions. 

Disorders of sensibility. — Here we come in contact with the 
consciousness of the patient — the ego of the patient — and we are 
to a certain extent at his mercy. In children this part of the 
diagnosis is limited to a very great degree on account of their 
inferior intelligence. For example, the sense of sight cannot be 
fully tested in these little patients, and when testing common 
sensibility we have to pinch and tickle them, and make use of 
other coarse tests. The special examination of the eyes and 
ears I will pass over for the present. 

We will now consider the perception and localization of sim- 
ple contact such as produced by the finger or a feather. The 
patient's eyes being closed, we touch him slightly in different 
parts, and ask him if he feels, and where he feels the contact. 

The question of " muscular sense " is an involved one. Some 
believe that the muscles have no proper sensibility, and that we 
know our muscular movements by psychic estimation of the 



566 METHODS OF DIAGNOSIS. 

force employed, yet there are some persons who cannot feel a 
tap or prick upon the skin of the leg, yet will feel firm pressure 
made upon the calf. There have been instruments devised for 
determining the amount of weight in grammes which a patient 
can distinguish. We test sensibility to pain in various ways. 
The use of the hot iron and matches I object to. We are not 
allowed, in an examination, to adopt such methods as will result 
in scars. A faradic wire brush is harmless, produces no scar, 
and is really more painful than cutting or burning, as I have re- 
peatedly seen ; and a clean, sharp needle is not objectionable. 

The brothers Weber, of Leipsig, gave us forty years ago a 
form of resthesiometer, which is much like a shoemaker's rule, 
with one end stationary. 

Another form of sesthesiometer is made like a compass, with or 
without a vernier. All sesthesiometers should have dull points. 
Dr. Birdsall has devised an improvement upon the former instru- 
ment. It consists in the attachment of a point at one end of the 
instrument, so that a patient can be pricked at will. We know 
from Weber's researches the distance at which two points of the 
sesthesiometer can be distinguished on all the parts of the body. 
The following are some of the more important according, to 
Valentin : * 

Millimetres. 

At the tip of the tongue 1.00 

" palmar surface of tips of fingers 1.50 

" " " second phalanges 3.24 

" " " first phalanges ....... 3.44 

" dorsum of the tongue 5.22 

" dorsal surface of fingers 8.12 

" cheek 9.4C 

" back of hand 14.50 

" skin of throat 17.27 

" dorsum of foot 26.10 

" front of sternum 33.07 

" middle of back .50.43 

In estimating pathological conditions I am in the habit ox 
making considerable allowance for normal variations. The 
points are to be applied to the surface of the skin simultaneously. 
This requires a certain degree of expertness on the part of an 
operator, and in order that the translation of the impressions be 

* For a complete table in lines (about 2 mm.) consult Flint's Text-Book of Physi- 
ology, p. 753. New York, 1881. 



METHODS OF DIAGNOSIS. 567 

correct, some degree of intelligence on the part of the patient is 
required. In testing the tongue, the patient is to indicate the 
answer by holding up one or two fingers. With the thumb and 
forefinger you can increase or decrease the distance between the 
points. 

One word about motor and sensory tests with a battery. For 
this purpose, either a faradic or galvanic current can be used. 
We use both currents for testing the condition of the connection 
between the nervous centres and the peripheral organs. I can 
only formulate a general law, and it is this : That in cases of 
disease of the brain in which the spinal cord and nerves con- 
tinue to act upon the muscles, even though the will has no 
influence over them, the electrical reactions are preserved. In 
cases of certain spinal lesions, especially in transverse lesions, 
the same law holds true. 

The affections of the spinal cord which destroy or involve the 
gray matter of the anterior horns will be accompanied, within a 
week or two weeks, by a loss of reaction in the paralyzed muscles 
and their nerves ; whereas, with a lesion of the spinal cord 
which leaves a certain part of the gray matter below the lesion 
uninjured, even though it be but a centimetre, we will get 
reactions in those muscles connected with the healthy part of 
the cord. In cases of injury to the spinal cord very low down, 
which destroy the lumbar enlargement, the muscles of the 
paralyzed legs undergo atrophy and lose their reaction to 
faradism. With a destructive lesion of the cervical enlargement, 
the same occurs in the hand and arm. The law may be stated 
in the following words : Destructive lesions of the gray matter 
of the cord abolish faradic reaction in the associated or depend- 
ent muscles. The same law is applicable to so-called peripheral 
paralysis, in which the nerve trunk has been divided or crushed. 
Hence, you see there is nothing pathognomonic determined by 
means of the electrical test ; it is of conditional value. 

I would like to say something about the use of the ophthal- 
moscope. I consider its use of great importance in the study of 
nervous diseases ; yet I feel that too much has recently been 
claimed for it. I would urge all of you to learn its use and to 
recognize the healthy fundus. By so doing you will get negative 
information ; and you should also learn to recognize atrophy of 
the optic nerve, neuro-retinitis, or choked disc, and the retinitis 
of Bright' s disease. These signs are positive and valuable indi- 



568 METHODS OF DIAGNOSIS. 

cations of disease. It has been claimed that by the ophthal- 
moscope we can determine the condition of the intra-cranial 
circulation, judging of this by the state of the retinal vessels. 
This I do not believe to be possible, partly because of the great 
normal variation in the circulation at the bottom of the eye ; 
partly because of the varying appearances of the vessels, accord- 
ing to the condition of the refraction of the eye ; and lastly, 
because it is not at all certain that there is any correspondence 
between the retinal and cerebral circulations. I am supported 
in these statements by leading oculists, who consider it a delicate 
task to decide whether a retina be hyper semic or anaemic 



Lectuee II. 

Gentlemen : — In my last lecture I spoke of the objective part 
of a diagnosis, and pointed out in brief the principal disturbances 
of function which we are able to recognize in an examination, 
and exhibited and described the instruments by means of which 
we detected and measured the degree of such disturbances. I 
referred to certain methods of diagnosis which fall within the 
province of other specialties, more particularly the use of the 
ophthalmoscope. To-day I wish to extend my remarks to cer- 
tain other methods of diagnosis, a knowledge of which is 
essential to the success of the nervous specialist. Among these 
may be mentioned auscultation and percussion in the physical 
examination of the chest and abdomen, the use of specula and 
tuning-forks in the examination of the ear and testing the hear- 
ing, the use of the laryngoscope in the examination of the larynx, 
the chemical and microscopical examination of the urine, and 
so on. 

Of course the neurologist cannot be expert in all these methods 
of examination ; but, on the other hand, he cannot be expected 
to make a satisfactory study of his patients without a certain 
degree of skill in these diagnostic manoeuvres. With respect to 
urine, it is especially important that he should be able to make 
a satisfactory examination of it. I may say that I have often 
had occasion, during the past five or six years, to prove the 
dependence of an obstinate and severe form of headache upon 
the existence of contracted kidneys. Detecting the presence of 
an excess of phosphates, or of an excess of urea, or the condition 



METHODS OF DIAGNOSIS. 569 

known as oxaluria, is often a very important factor in nervous 
diagnosis. It is not sufficient to make a single examination of a 
sample of urine in a test-tube, by boiling it and adding acid, but 
the amount of urine secreted in twenty-four hours should be 
known, and, from repeated examinations of it, the existence or 
non-existence of morbid conditions noted. 

By an examination of the genital organs, both male and female, 
much important information may be derived. 

A knowledge of the presence of versions, flexions, or tumors 
of the womb, ovarian disease, deep-seated stricture, or narrow 
anterior urethra, and many other abnormal conditions of the 
genital tract, will lead to the adoption of appropriate treatment ; 
whereas, without such knowledge, drugs may be prescribed and 
electric batteries used, for an indefinite time, without relief. 

I next projDose to speak of the principles of diagnosis, and 
will divide the disorders to be diagnosticated into two classes, 
organic and functional. This division presupposes a difference 
in the method of examination. The logical difference between 
the methods of study is very marked. The complete and 
satisfactory recognition of organic disease of the nervous 
system involves a triple diagnosis. It is arrived at inductively 
by means of the history given by the patient, by means of the 
testimony of friends, by means of the various methods of phys- 
ical examination, and, to a certain extent, deductively by 
knowledge you have acquired from experience, books, etc. 

The first diagnosis is that of the symptoms, and these may be 
considered as constituting what the Germans call the " symptom 
group." Second, we make a diagnosis of the location of the 
lesion, and it is this diagnosis which is just now interesting 
observers most. In the third place, we have to determine the 
nature of the lesion, which is, perhaps, of the greatest practical 
importance to the physician. We first determine the symptoms, 
next the situation of the lesion producing the symptoms, and 
afterward try to determine the pathological nature of the lesion. 

The first diagnosis is made exclusively from a history of the 
case and an objective examination. We learn from the state- 
ments of the patient and friends, and an ocular examination, 
what has taken place during the few days or weeks preceding. 
We determine, by methods pointed out in the last lecture, 
whether there exists paralysis, spasm, ataxia, anaesthesia, etc. 
The mental symptoms to be noted are loss of memory, delusions, 



570 METHODS OF DIAGNOSIS. * 

or uncontrollable manifestations. "We thoroughly overhaul the 
patient physically and psychically, and we determine what func- 
tions are well performed, and which are interfered with. During 
the next few weeks you will have in every lecture an illustration 
of how to make this diagnosis : for example, a patient will come 
into the clinic complaining of weakness of the muscles of the 
face, arm, and leg, upon one side of the body. 

We determine the existence of this condition by the testimony 
of the patient and his friends, by inspecting the patient, by the 
application of tests which have been already described to you, 
and from the data thus collected decide that the case is properly 
one of hemiplegia. Again, a patient may come in complaining 
of weakness of both legs, while the arms are normal, and we 
decide that he is suffering from paraplegia. A patient present- 
ing with no paralysis and no anaesthesia, but with an inability to 
direct the movements of his legs, we say he is suffering from 
inco-ordination or ataxia. If a patient presents with one eye 
turned outward and a drooping of the lid, we designate this 
condition as one of ptosis with strabismus. If a patient has 
loss of sensibility, we call it anaesthesia, and ascribe particular 
names, in accordance with the distribution of the anaesthesia. 
When anaesthesia of one-half of the body exists, we call it hemi- 
anaesthesia. If, upon examination, vision is found to exist only 
in one-half of the visual field, we call the condition one of hemi- 
opia. In this manner we indicate the condition of the various 
organs throughout the body, and determine in what way they 
differ from the normal, and to the conditions found to exist we 
give certain names which represent the symptom-group. 

Sometimes we are only able to discover a single symptom, and 
have to go on to the next diagnosis. My observations have led 
me to believe that in making the first diagnosis, the testimony 
of the patient is too frequently used as a sufficient guide, and 
pains are not taken to go over the body and carefully determine 
the extent of paralysis, ataxia, or areas of anaesthesia, and make 
a record of what is found. There is often a lack a definiteness 
in examinations of nervous cases which practitioners would not 
allow in chest diseases. From the time of Laenec no physician 
has considered his examination of the chest complete without 
having determined the nature and character of the signs, so that 
he could tell another physician what he had seen or heard, in 
such a way as to lead him to a correct diagnosis. We are 



METHODS OF DIAGNOSIS. 571 

attempting to apply the same exact method to the study of 
nervous diseases, and are making very great progress. 

The second diagnosis, that of the location of the lesion, is of 
importance. It is not directly dependent upon observations made 
with our eyes, instruments, etc., but upon anatomical and phys- 
iological knowledge. It is very seldom that a neural lesion is 
visible, except in cases resulting from injury or external violence. 
We have to determine the situation of the lesion from the symp- 
toms present, by means of our acquired knowledge of physiology 
and anatomy. Hence it is that exact and minute anatomical 
knowledge is more essential for the diagnosis of nervous diseases 
than for that of any other. 

I will take up some of the symptom groups of which I spoke 
a few moments ago, as determined hypothetically in my remarks : 
for example, that of hemiplegia. We revert to our acquired 
knowledge concerning the nervous supply of the paralyzed parts 
derived from the spinal cord and brain. We also revert to the 
experiments made upon the central nervous system of higher 
animals within the last fifteen years, and our empirical knowl- 
edge of lesions discovered after death in cases of hemiplegia 
studied during life. For the present I will rely more particularly 
upon anatomical and experimental data. We know that the 
limbs of one side of the body receive innervation from the 
opposite side of the brain. You will hear it said that this law 
is not valid ; but I say to you it is a good law, and a knowledge 
of it will be of great help to you in the study of nervous diseases. 
The few exceptions which are quoted in support of the idea of 
its invalidity are capable of many interpretations which leave 
the law untouched for all practical purposes. I propose to 
discuss this matter of the crossing of nerve fibres from one side 
to the other, in a subsequent lecture. Bearing in mind, then, 
that either side of the body is innervated from the opposite side 
of the brain, we at once locate the lesion on the opposite side 
from that in which the paralysis is found to be present in our 
hypothetical case of hemiplegia. Partly from the study of 
anatomy, partly from the study of embryology, and partly from 
a knowledge of what recent experimental physiology has taught, 
we know that the whole of one side of the brain has not the 
power of moving all the opposite side of the body. Let us 
suppose a case of left hemiplegia with the lesion in the right 
hemisphere. I may remark that the whole right hemisphere is 



572 METHODS OF DIAGNOSIS. . 

not connected with the opposite cheek, arm, and foot. Eecent 
experiments have shown that a relatively small part of the right 
hemisphere has power over the left cheek, hand, and leg, and this 
part of the hemisphere is in the median region, and embraces a 
small number of convolutions — certainly not more than half of 
them. We have records of positive knowledge, to the effect that 
the anterior and posterior extremities of the hemispheres have 
no motor power over the opposite side. Still basing ourselves 
upon anatomical researches and physiological experiments, we 
know that the muscles of the left side of the face are in- 
nervated by a small part of the right frontal lobe, we know that 
the upper extremity is innervated by a small part of the brain 
known as the ascending frontal and parietal convolutions. "We 
further note that the part of this right hemisphere which is 
connected with the leg is situated at a different point, nearer the 
median line, near and in the longitudinal fissure, and more 
posteriorly. In other words, we have determined with great 
accuracy the motor area of the right hemisphere, and the centres 
for the movements of the cheek, arm, and leg. With respect to 
the sensory function of the hemisphere our knowledge is not 
so exact, but we know that loss of sensibility on one side of the 
body indicates a lesion in the opposite half of the brain ; that 
right hemi-anaesthesia indicates a lesion in the left hemisphere — 
one situated in all probability in parts posterior to the motor 
area. These are not theoretical guides ; they are valuable life- 
laws, and there has not a year passed, within the last five years, 
that I have not seen cases illustrative of them, and verified them 
by post-mortem examination. Bearing upon this point, I may 
say that I published two cases this year,* in which the 
diagnosis was made, by means of a knowledge of these laws, 
with such accuracy that we were within 1.5 to 3. centimetres 
of the actual seat of the lesion. In a number of my cases the 
lesion was found to be situated exactly where it was diagnos- 
ticated during life. Records of similar cases may be found in 
American, English, and Continental journals generally. 

We are also able to locate, upon similar anatomical and 
physiological principles, lesions of the spinal cord. In para- 
plegia we can determine the height of the lesion quite accurately, 
by means of our knowledge of the points at which nerves are 
given off trom the spinal cord. To quote a case : a patient falls 

•-' Journal of Nervous and Mental Diseases, July, 1881, p. 510, vol. viii. Also 
p. ... of this volume. 



METHODS OF DIAGNOSIS. 



573 



and receives a dislocation and fracture of the seventh cervical 
vertebra, compressing the cord at this point. The patient at 
once presents anaesthesia and paralysis below the clavicles and 




The above woodcut is modified from Fcrrier : letters and figures the same.— S, fissure of Sylvius ; 
c, fissure of Rolando ; po, parieto-occipital fissure. A, ascending frontal gyrus ; B, ascending 
parietal gyrus ; F 3 , third frontal gyrus ; r 2 , gyrus angularis. Circle I., seat of. lesions which 
(on the left side) cause aphasia. Circle II., scat of lesions which convulse or paralyze the 
upper extremity of the opposite side. Dotted Circle III., seat of lesions which probably con- 
vulse or paralyze the face on the opposite side. Dotted Oval IV., seat of lesions which con- 
vulse or paralyze the lower extremity of the opposite side. These districts receive their blood 
supply from the middle cerebral artery. 



in the distribution of the ulnar nerve. Now we know, from 
anatomical and some curious electrical " :: " examinations, that the 
fibres of the ulnar nerve arise from the lower part of the cervical 
enlargement, and that its trunk is made up by the last cervical 
and first dorsal nerves. Hence it is that compression of the cord 

* In two or three eases of spinal irritation I have noticed that placing the 
cathode over the sixth and seventh dorsal vertebra?, with the anode near by upon 
an indifferent part, and passing a strong current, the patient, though devoid of 
any anatomical knowledge, has described a pricking sensation in the little and 
ring lingers of each hand. This is evidence of the cathodal excitation of the origin 
of the ulnar nerve. 



574 METHODS OF DIAGNOSIS. • 

at this point gives rise to paralyses of parts supplied by this 
nerve. When I come to speak of the diseases of the spinal cord, 
I will give in detail the rules for determining the height of any 
lesion, by means of which a diagnosis of extreme accuracy can 
now be made. We can locate a lesion in the anterior and pos- 
terior portions of the cord, with reference to the white' and gray 
matter. We know that paralysis, accompanied by great muscular 
atrophy and degenerative electrical reactions, is due to a lesion 
in the anterior gray matter of the spinal cord. We know that 
in ataxia of the legs and arms, in which there is no true paralysis, 
the lesion is strictly limited to the posterior white columns. A 
patient comes in with a stiff gait, with crossing of the legs, but 
without anaesthesia or ataxia ; we are certain that the lesion is 
in the lateral columns. In peripheral paralysis — as, for example, 
when due to injuries of the nerves — a diagnosis is usually very 
easy to make, for we have an injury or scar to guide us. Or a 
nerve may be cut in a surgical manoeuvre, and we can at once 
determine the seat of the lesion. But, in some cases, the seat of 
the lesion is not apparent, and we must judge of it by medical 
logic. In the diagnosis of such cases we are very much helped 
by an anatomical law, which you probably have not found in 
your books, and which summarizes the distribution of the sensory 
and motor filaments of nerve trunks. I refer to the law of Yan 
der Kolk, namely, that a spinal nerve gives its motor branches 
to the muscles as instruments of motion, and its sensitive 
branches to the part moved." In other words, throughout the 
body the sensitive branches of a mixed nerve run to the part of 
the skin which is moved by the muscles receiving motor fila- 
ments from the same nerve trunk. It is very easy to call to 
mind examples of this law. A sciatic nerve, for example, sends 
its sensory filaments to the calf of the leg and the foot, which 
parts are moved by the posterior thigh muscles and both sets of 
tibial muscles, which receive their motor filaments from the 
sciatic. In the arm the musculo-cutaneous nerve gives motor 
fibres to the biceps and brachialus anticus, and its sensory 
filaments go to the integument of the forearm, which is the 
part moved by the above-named muscles. 

Wherever you study this law you will find it absolute. You 

* Schroeder Van der Kolk: "On the Minute Structure and Functions of the 
Spinal Cord and Medulla Oblongata," Translation of the New Sydenham Society, 
pp. 6, 7. London, 1G59. 



METHODS OF DIAGNOSIS. 575 

may meer with some apparent exceptions, but they are only 
apparent. An apparent exception is found in the head, where 
the trigeminus plays the part of sensory roots for most of the 
cranial motor nerves. Studied in the light of this law, a patient 
presenting anaesthesia of the little and ring fingers, and outer 
part of the palm, with paralysis of the interossei and inner half 
of the thenar group, has a lesion of the ulnar nerve, probably 
above the wrist. If the flexor carpi ulnaris is paralyzed, the 
lesion is certainly above the elbow. Again, paralysis of the 
extensors of the carpus and fingers, with anaesthesia of the dor- 
sum of the hand on its radial side, indicates a lesion of the mus- 
culo-spinal nerve. 

We now come to the third diagnosis — that of the nature of the 
lesion. This should not be made until the others have been 
determined carefully ; and, here again, Ave use entirely different 
principles of logic. This diagnosis is more empirical — more 
uncertain. The third diagnosis can be best made by the phy- 
sician who has had the greatest experience with disease in gen- 
eral ; and here comes in the strongest argument for the post- 
ponement of special practice until you have acquired a thor- 
ough knowledge of general pathology. It is just here that one 
realizes the insufficiency of normal anatomical and physiological 
study. It makes no difference what the symptoms are, or where 
the lesion is located, for that does not determine what the lesion 
is. Take, for example, a left hemiplegia with paralysis of the 
left cheek, arm, and leg. The patient may have a tumor, a patch 
of softening, a hemorrhagic focus, a syphilitic formation ; he 
may have what is exceedingly rare — local anaemia, and the only 
way of determining which one of these is present is by our 
knowledge of pathology. To this end we determine the tem- 
perature, pulse, and other symptoms ; the conditions of the 
arteries ; the presence or absence of the signs of degeneration 
throughout the body, and the presence or absence of the signs 
of contracted kidneys and heart disease. To determine with 
certainty that a hemorrhage has taken place in the brain, you 
must ascertain the previous diathesis and the general condition 
of the body. The rupture of vessels in the brain is a mere acci- 
dent ; the same statement may be made in regard to softening. 
This latter condition is often due to organic cardiac disease, 
producing embolism of a healthy cerebral artery, and sometimes 
also of arteries at the periphery, which is more difficult to 



576 METHODS OF DIAGNOSIS.. 

make out. It is likewise caused by local obstructions in the 
arteries of the aged or prematurely old, and of syphilitic sub- 
jects. The same general rules apply to the study of diseases of 
the spinal cord. The nature of the lesion is to be determined 
by the pathological condition of the patient, and by means of 
empirical knowledge acquired by post-mortem examinations. 
For example, if a child presents with enlargement of the head 
and separation of the sutures, we know, as a matter of expe- 
rience and post-mortem examination, that there is internal hy- 
drocephalus, the most common cause of which is tubercle ; and 
we also say that it is probable that the tubercle is compressing 
the aquseductus Sylvii. In the same way we determine the dif- 
ference between syphilitic and non-syphilitic subjects. 

I go on, now, to the diagnosis of the functional disorders of 
the nervous system. This subject does not admit of as system- 
atic a presentation as the former. In many of the functional 
diseases of the nervous system we know very little about their 
pathology, so we do not complete the third diagnosis ; and as 
the disease is functional, we need not consider the second. For 
example, chorea is an obvious symptom which we can recognise 
at a glance. If we attempt to localize the lesion or disease, we 
cannot go any farther than to make the statement that a func- 
tional lesion is situated in the brain, and that it is very proba- 
bly a cerebral affection. We make this statement upon the 
remarkable fact that the disease is often hemiplegiform. We 
cannot go any farther, and, as regards the lesion of chorea, we 
are entirely in the dark. We can only offer speculations based 
upon a few post-mortem examinations, which, in my opinion, 
are worth very little. The same is true of epilepsy, hysteria, 
and neuralgia. The best we can do is to state the symptoms 
definitely, and not attempt any rigorous diagnosis of the disor- 
der, or try to determine the nature of the lesion, in the same 
sense as Ave do lesions in organic affections. But yet there is a 
diagnosis to be made of the nature of the lesion, or, as I would 
put it, the condition of the patient. This consists, after we have 
determined that the patient has chorea, epilepsy, or neuralgia, 
or " neurasthenia," of making an inquiry into his general condi- 
tion, the state of the circulation, arterial tension, and, in some 
cases, the action of the heart, and the condition and mode of 
action of certain organs which we know, from empirical knowl- 
edge, to be connected with functional disorders. For example, 



METHODS OF DIAGNOSIS. 577 

•within the last seven years we have learned, with great positive- 
ness, that certain cases of headache are due to straining of the 
eyes. In studying cases of headache, especially cases of long 
standing, it is desirable — I may say imperatively necessary — to 
study the condition of the eyes. Thanks to the labors of Drs. 
Weir Mitchell and William Thomson, of Philadelphia, we have 
been able to relieve a large number of cases of " bad head," as 
I call them. In the same way, with reference to hysteria, we 
examine the patient, not simply for anaemia and mal-nutrition, 
but also for uterine and ovarian disease or vulvar irritation. 
This will lead us many times to a correct understanding of the 
case. There is quite a large class of cases in which the symp- 
toms are nervous, the patients experiencing a curious depres- 
sion, pain in the back and head, aching in the limbs, and many 
other symptoms, chiefly sensory, all of which we are generally 
unable to refer to any definite cause, and they are known under 
the name of " neurasthenia." This name is all very well, pro- 
vided we go farther. One theory as to the cause of these symp- 
toms — and it is held by some very respectable authorities — is 
that they are due to a variation in the amount of blood in the 
spinal cord and brain. I myself confess to very little faith in 
this view. I think it can be shown that there can be but slight 
changes in the amount of blood present in the spinal cord, and 
that these are not accompanied with symptoms. My own experi- 
ence is that the symptoms are often produced by conditions of 
general mal-nutrition, which can be classified conveniently under 
the heads of litha3inia, or sub-oxidation of the tissues. Some 
other cases are due to weak eyes, some to ovarian diseases, 
some to the use of tobacco, sexual excesses, etc. Cases of so- 
called hyperemia of the brain, now so fashionable, are to be 
studied in the same way from the standpoint of the general 
physician ; nearly all such cases being, according to my expe- 
rience, resolvable into instances of lithsemia, eye-strain, cardiac 
disease, renal disease, irritation from the sexual organs, etc., 
leaving exceedingly few cases of hyperemia, if any. The diag- 
nosis of lithsemia is to be obtained by the examination of the 
urine, and the usual method of doing this is very misleading. 
If the patient is told to bring a bottle of his urine, the first that 
is passed in the morning, it is found of high specific gravity, 
high color, acts upon litmus paper forcibly, and may deposit 
urates ; or the microscope shows, in a few hours, oxalate of lime. 
37 



578 METHODS OF DIAGNOSIS. 

To judge in this way from one specimen, I believe to be a most 
superficial practice. I am not willing to say that a patient is a 
subject of lithsemia or oxaluria, unless I have examined speci- 
mens of urine on successive days, for the reason that the nrine 
varies from day to day, and during each day, owing to the vary- 
ing conditions of the body. One or two examinations are of very 
little help. In my practice I make a number of examinations — 
three or four — of urine passed morning, noon, evening, and at 
bed-time ; and I am unwilling to use the term oxaluria unless I 
find this condition indicated by most of the specimens. By this 
means the average condition of the urine in twenty-four hours 
can be determined. 

I will make a few remarks in regard to taking the history of a 
case. Very few medical men take good notes. It is a very diffi- 
cult matter to write a history so that different medical men, 
reading it, would come to the same conclusion in regard to the 
case. Of course we first obtain the patient's story. We have 
to guide the patient, so that we can arrange the facts which he 
gives us in some logical order. It is desirable, in many cases, 
to give some illustration as to the behavior of the patient, men- 
tal manifestation, etc. A few words with the friends of the 
patient, as to what they have observed, is often serviceable, and 
sometimes it is well to question the patient alone. In taking 
down the notes we form a dim mental outline of the diagnosis, 
in advance. It seems impossible to take a history without doing 
this. We next carefully record the objective symptoms pre- 
sented by the patient, and thus reach what I have termed the 
first diagnosis. In some cases we may locate the lesion at once 
from the symptoms, and even determine the nature of the lesion. 
This is by no means infrequent, and the taking of the history 
will be the only time you need to give to the consideration of 
the case. In other instances you have to go on, step by step, 
and carefully determine the points in the diagnosis which I have 
referred to. We are often, in the course of this preliminary and 
semi-conscious notion of the nature of the case, led to doubt the 
patient's statements, and it is well to make a mental memoran- 
dum of these points, and, after the history is completed, ques- 
tion the patient again, or ask information of others. This is 
very necessary in cases where we investigate such causes as 
sexual irregularities and syphilis, family taints, etc. 



THE EFFICACY OF IODIDE OF POTASSIUM IN NON- 
SYPHILITIC OKGANIC DISEASES OF THE CEN- 
TEAL NEKYOUS SYSTEM.* 

I intend this paper to be inquiring and suggestive rather than 
didatic, and hope that it may be the means of eliciting the expe- 
rience and opinion of others whose opportunity for observation 
has been greater than my own. 

There has appeared to be in the minds of those members of 
our profession whom I have had the pleasure of knowing, a half 
avowed belief in the specific action of potassium iodide ; that it is 
a sort of reagent with respect to syphilis. Many go so far as to 
assume this position : that if an individual present a given 
symptom, but denies having had syphilis in any form, and if 
that symptom disappear under the use of the iodide of potas- 
sium, then the symptom must have been syphilitic in spite of 
the patient's denial. I have repeatedly heard medical teachers 
say of a symptom : "Give iodide, and we will see if it is syphi- 
litic or not," the implication being that if non-syphilitic the 
symptom would not be removed by the drug. 

The consequences of such a belief may be serious. On the 
one hand, a physician holding the above views will be indis- 
posed to try the drug in full doses in cases of organic cerebral 
disease where there is no indication of syphilis ; a negative 
position which might cost the lives of several patients in the 
course of the physician's life. 

On the other hand, after curing certain symptoms with iodide 
of potassium in a person who claims never to have had syphilis, 
the physician becomes convinced that the patient has con- 
sciously or unconsciously deceived him ; that he is syphilitic. 
Such a view will powerfully influence the physician in his further 
relations with the same patient as regards his interpretation and 
treatment of other affections which may show themselves, and in 
respect to the advice to be given as to marriage, child-bearing, 
etc. 

* Read before the New York Neurological Society, January 3, 1882. Reprinted 
from the Archives of Medicine, Vol. IX., No. 3, June, 1883. 



580 POTASSIUM IODIDE IN NON-SYPHILITIC DISEASES. 

A more physiological view of the action of remedies upon 
organic diseases, and a careful examination of clinical evidence 
would, it see*ins to me, prevent one from assuming the specific 
action of iodide of potassium in syphilis.* 

As regards the general question, that of the specific action of 
remedies, I have not the time to present an argument to show 
its fallacy ; and probably I could not do the matter justice. The 
belief in the specific action of drugs, i.e., of the action of drugs 
against disease as such, is a comfortable belief to have ; it 
apparently solves many of the problems of e very-day medical 
practice. But many believe such a doctrine to be just as falla- 
cious and unscientific as it is comfortable. I wholly agree with 
those who think this, and who believe that remedies act on the 
organism as a whole, or on its apparatuses, or on some of it's 
tissues, or on its constituent chemical ingredients, in a physio- 
logical way, i.e., by and through the operation of chemical and 
physiological laws already operative in the animal body. 

In the second place, as to clinical evidence. This is the pur- 
pose of my paper ; to place before you some cases which 
I think support the proposition that the iodide of potassium is 
efficacious, more or less, in non-syphilitic nervous diseases. In 
going through my case-books for the purpose of finding such 
illustrative cases, I have exercised great strictness, and as a 
result I have had but very few histories to read, and these I 
have condensed as much as possible. 

My cases are nine in number, arranged in two groups. 

In the first group are three cases of organic disease of the 
brain, in which many threatening symptoms were relieved, in 
some of them immediately and on different occasions, by the 
free use of the iodide. In all these cases post-mortem examina- 
tions were made, and the gross lesion found. In all of these 
there was no clinical or histological evidence of syphilis. 

In the second group are six cases which are still living, some 
cured. I divide this group into two classes, a and b. The 
former is made up of three cases of organic cerebral disease in 
the adult, two of them cured, and the third twice relieved of most 
of his symptoms by the iodide. Class b is composed of three cases 
of basal meningitis with optic neuritis in little children, who 
recovered rapidly while using the same remedy. I attach much 

* For the opinion of various authors on these points see the end of the article . — 

[R. W. A.] 



POTASSIUM IODIDE IN NON-SYPHILITIC DISEASES. 581 

less importance to these infantile cases, because of the doubt 
there must remain as to their having been anything more than 
optic neuritis. Still they have a certain value in a purely clinical 
paper like this one. 

FIRST GROUP. 

Case I. — Tumor of left crus cerebri. G. W., set. nine years. Seen 21st 
September, 1874. Had been a healthy boy. Parents and other children 
healthy. 

In the month of April had measles without head symptoms. Early in May 
awkwardness of right side of body; gradually extending paresis from arm to 
leg ; face unaffected. In August he walked like an old man, with his right 
shoulder drooping, right arm almost motionless; speech normal. During 
July and August had a great deal of occipital headache, relieved by cold. 
Since August, pain in various parts of head; more in front and behind. Of 
late the pain has been sharp, occurring in paroxysms, accompanied by nausea 
and vomiting. Irregular jerking movements of the paralyzed side, first noticed 
in August; none in the face. In the last ten days as above, but weaker; able 
to walk a little alone. Four weeks ago double vision, and since a squint; 
parents thinks vision is otherwise normal. The pulse has been observed by 
the family physician, Dr. Banks, to be habitually very slow, about 60, and at 
times irregular. Has had no convulsion or loss of consciousness. No recent 
injury to head, and never disease of the car. Paroxysms of headache and 
vomiting often occur in the middle of the night. 

On examination I found patient conscious, with right-sided hemiplegia; 
lower face affected. There was also palsy of the left sixth cranial nerve, 
producing convergent strabismus and diplopia. Slight rigidity in fingers of 
right hand. When patient attempts voluntary movements there is well- 
marked ataxia of the right upper extremity; no anaesthesia: pupils normal; 
vision impaired in left eye ; opthalmoscope shows choked discs ; on attempting 
to walk staggers very much; complains of vertigo; left side of body normal. 

I advised the application of blisters behind the ears, and internally a 
saturated solution of iodide of potassium. On October 2d, patient being 
weaker, he, after vomiting in the morning, rather suddenly passed into coma. 
No couvulsions. After forty hours regained consciousness with more paralysis 
on the right side, the same ataxia, and nearly complete loss of vision. 
Paroxysms of pain and vomiting never returned after this. 

On October 4th, improvement began in right side and continued; mind 
clear. 

On October 11th, is taking ten drops of the iodide solution three times a 
day ; can move right leg. 

October 20th, takes eighteen drops three times a day ; more strength in arm 
and leg. 

November 17th, takes forty-five drops three times a day; can raise himself 
up in bed. November 21st, taking sixty drops thrice a day; walks with 
some help. 



582 POTASSIUM IODIDE IN N ON- SYPHILITIC DISEASES. 

Until December 8th this maximum dose of sixty drops was continued ; after 
that date it was gradually reduced to forty drops on the 13th. Constant gain. 

I saw G. on December 14th. He then walked about alone with a half- 
ataxic, half-choreic action of the right side. He presented a partial right 
hemiplegia, face and body, and complete palsy of the left sixth nerve ; no 
anaesthesia. The oj^tic nerves showed commencing white atrophy ; no per- 
ception of light ; no muscular atrophy ; no headache. 

My friend, Dr. J. C. Shaw, of Brooklyn, then took immediate charge of the 
case, though I saw it occasionally with hirn the first year. Iodide omitted in 
winter. 

In 1875, from early in April to end of May, severe symptoms — headache, 
vomiting, cramps in calves of legs, and priapism — were relieved by the iodide 
increased slowly from .60 to 2.3 three times a day. After having been in 
bed for weeks, is again able to walk about with some right hemiparesis 
and hcmichorea. 

Dr. Shaw saw patient rarely after that until the spring of 1880, when 
after a series of anomalous symptoms he died. The autopsy made by Dr. 
Shaw revealed complete compression of the left eras cerebri and pressure on 
adjacent parts of the pons and cerebrum by a large irregular tumor. 

The microscope showed it to be chiefly a sarcomatous growtli with here 
^and there large cells, either mother cells or modified ganglion cells. 

Case II. — Cerebellar tumor — internal hydrocejjhalus. Paul K., aged eight 
years. Seen in consultation with Dr. Malcolm McLean, of Harlem, on 
November 17, 1879. 

In the past eight or nine months has suffered from diffused headache, 
attacks of vomiting, double exophthalmus, and staggering gait. Has been 
seen by many physicians, most of whom attributed the symptoms to 
"malaria." Child grew steadily worse in spite of treatment on this theory, 
and in August was taken to the Catskill Mountains. "While there seemed 
worse; headache severe; staggered and vomited; was very weak. In Sep- 
tember came under Dr. McLean's care, with above symptoms; no paralysis 
or impairment of intelligence. Parents stated that there have been no 
epileptiform seizures and no fever. Small doses of iodide of potassium 
caused improvement. Treatment suspended in October. 

In last two or three weeks again worse ; severe headache, much of it occip- 
ital and frontal. Great enlargement of the head and separation of sutures. 
Marked exophthalmus — staggering gait and pseudo-paraplegia, A few days 
ago there occurred sudden recession of the exophthalmus, and simultaneously 
there appeared a soft, fluctuating tumor or swelling in the right occipital 
region. 

There is no history of injury to the head, or of causes of tuberculosis. 

Examination. — Child pale but intelligent; speech normal; vision seems 
good by finger and color tests, but the ophthalmoscope shows double neuro- 
retinitis (choked disc) of moderate degree. No facial or head paralysis. 
Co-ordinates perfectly well. All the cranial sutures are wide open ; anterior 
fontanelle closed ; forehead not very prominent ; no exophthalmus now. In the 
right occipital region, in the vicinity of the lambdoid suture, is a soft, com- 
pressible subcutaneous tumor, walnut size, whose contents beat synchronously 



POTASSIUM IODIDE IN NON-SYPHILITIC DISEASES, 583 

with the pulse. The appearance of this swelling caused a relief to all symptoms 
except debility. It might be supposed that this swelling contained fluid 
derived from the hydrocephalus, but from its location I felt considerable 
doubt as to this. 

Patient walked feebly in a staggering way ; no paralysis or ataxia. 

I made the diagnosis of internal cerebral hydrocephalus, probably from 
tumor of the cerebellum comprising aqueduct of Sylvius. I advised against 
puncture and aspiration of the newly formed sac, and recommended larger 
doses of potassium iodide. 

Dr. McLean kindly wrote me December 30th of this year : 

II We immediately increased the iodide of potassium from ordinary doses 
to from 1.5-2.4; so that he received amounts of the medicine varying from 
6.-9. per day. The medicine never disturbed his stomach, and his symptoms 
were certainly ameliorated by the larger doses, which were continued for four 
months without interruption. The pains in the head were undoubtedly con- 
trolled by the medicine." 

The child died in the early spring of 1880, and an autopsy by 
Dr. McLean showed a cerebellar tumor compressing the aquse- 
ductus Sylvii and the vense Galeni, thus causing ventricular 
dropsy. Tumor was fibro-sarcoma. 

It was well that the externally presenting sac was not punc- 
tured, for it turned out to be the extruded lateral sinus. 

Case III. — Tumor of the cerebellum. J. J., aged 14 years. Seen first on July 
29, 1880. Had been a healthy boy. At three years had whooping-cough 
severely with several convulsions. Parents deny convulsions or petit-mal 
since. 

About January 1, 1876, J. fell heavily on a stone walk, striking his head so 
hard as to make him unconscious; did not vomit. In April of that year he 
began to have curious vomiting spells in the early morning, followed by vio- 
lent occipital headache. The patient describes the vomiting as not preceded 
by nausea, and the rejected matters contained no food. After having had 
these attacks for several days, one afternoon J. fell unconscious and had a 
general convulsion, repeated in the night. After this J. carried his head 
inclined to the left shoulder, his occipital headache continued, and he had a 
stiffish feeling in the neck. The vomiting did not return, and there was no 
delirium. 

At the end of May he had gradually become paralyzed generally, but more 
on the left side. He had pain in his eyes, with rapid failure of sight. Drs. 
Agncw and Knapp found white atrophy of the optic nerves. No recovery of 
sight since. (It is very probable that during April there had been choked 
discs, with fairly preserved vision.) Speech was never affected. 

Spontaneous improvement occurred, and in July, J. was able to sit up, and 
gained rapidly in all respects except sight. Some disability in use of hands 
and walking remained. He grew well, and was taught at the school for the 
blind. Has been very intelligent. No special symptoms occurred for nearly 



584 POTASSIUM IODIDE IN NON-SYPHILITIC DISEASES. 

four years, viz. : until May of this year (1880) when lie began to have attacks 
of occipital pain and vomiting ; occasionally had pain in left mastoid region, 
and numbness in left side of chin, and around left corner of mouth. A few 
days ago was found unconscious ; probably had had a convulsion. Admits 
occasional dizzy or unconscious spells of momentary duration. Is still able to 
be up all day, dressed. 

Examination (July 29th). — Eyes in left conjugate deviation; sightless; pu- 
pils wide; nerves bluish white. Tongue straight; right hand, 20°; left, 25°. 
Left leg stronger than right. Consequently has right hemiparesis ; no 
tendon reflex at knees ; walk is staggering, more off toward his left. There 
is no distinct ataxia, and the walk is not of the type called cerebellar; no 
anaesthesia. I gave him a mixture of bromide and iodide of potassium, of 
each salt about 1. at night, ; quinine, sherry wine, and food. 

Sept. 29th. — Patient improved wonderfully in first month of above treat- 
ment. Early in September had a sort of convulsion, and since more or less 
occipital pain ; objective symptoms as above. 

Nov. 14th. — Poorly of late. Occasional attacks of occipital pain and vomit- 
ing (without nausea); rather frequent attacks of petit-mal, or perhaps more 
strictly speaking syncopal attacks, usually associated with headache. In last 
twenty-fours hours has been semi-comatose, at times vomiting. Pulse weak. 
Ordered ext. digit, fid., .0C, and tr. opii .18 by mouth. 

Nov. 16th. — To-day better, and is ordered ten drops of a saturated solution 
(equal parts) of iodide of potassium three times a day, to be increased each 
day by two drops at a dose. The small dose of bromide heretofore given 
(about 1.) stopped. 

Dec. Gth. — The iodide has been gradually increased to forty drops three 
times a day, with the best results ; no headache or vomiting or syncope since 
beginning iodide. No bromide. Rich food and sherry. 

Examination shows a new symptom, viz., occasional twitching and distinct 
ataxia of the right upper extremity; none in the legs; perhaps a trace of 
ataxia in left hand. Absolutely no tendon-reflex at knees. Right hemi- 
paresis; no anaesthesia: face not paralyzed. Is up all day, and walks out of 
doors occasionally. Iodide to be gradually reduced. 

Several times during the winter and spring of 1881, J. had a return of occip- 
ital pain and syncopal attacks; more recently of cervical pain also. These 
attacks were invariably cut short by blistering the nape of the neck or the 
mastoids, and by giving at once the full doses of iodide of potassium, viz.j 
from forty to fifty drops three times a day. Previous to December 21st 
the blisters had not been used, so that we may conclude that the more 
potent agent, in affording relief to the very distressing and threatening symp- 
toms was the iodide of potassium. The relief usually appeared in two or 
three days. Between the exacerbations the dose of iodide was from ten to 
twenty drops, and he had a variety of tonics. 

The summer of 1881 was exceptionably favorable for J. He was very well 

and happy. Though blind and slightly ataxic he enjoyed life, and was very 

cheerful. He had learned to do many delicate manipulations with his hands. 

Oct. 12th. — J. was seized with convulsions, vomiting, and a gradually 



POTASSIUM IODIDE IN NON-SYPHILITIC DISEASES. 585 

increasing pyrexia. Died comatose on 14th at midnight, with axillary tem- 
perature of 39.5° C. 

Autopsy showed a tumor involving a large part of the inferior portion of 
the right hemisphere of the cerebellum, forcibly compressing the underlying 
portion of the mesocephale. The upper three-fourths of the same right hemi- 
sphere of the cerebellum was occupied by a cyst containiug a clear fluid. The 
bottom of this cyst is the solid tumor referred to above. The cyst has dis- 
integrated the upper and middle portions of the vermis superior. 

The cerebral convexity showed abundant heavy patches of purulent sub- 
arachnoid meningitis, chiefly along vessels. The microscope showed, in fresh 
serum preparations, tubercle-like masses round about vessels, and at their 
bifurcation. This meningitis was the cause of death. 

A microscopic examination of the solid cerebellar tumor showed the sub- 
cystic tumor to be mainly sarcomatous, cellular and vascular, with foci of 
amyloid degeneration. 

The family are all unusually healthy. Besides J. there arc seven living 
children who are pictures of health. The father and mother are perfectly 
well, and always have been. The teeth of patient were normal, and he was a 
well-developed lad of rather hydrocephalic aspect. No suspicion of specific 
disease could be entertained in this case. 

SECOND GROUP, CLASS A. 

Case I. — Leftlicmi-para>sthcsia cured hj ]Jotassium iodide. Dr. J. K., U. S. A. 
set. forty-five years, seen December 8, 1877.' Had always enjoyed good 
health. AYhilc on duty in a Western State, December 13, 1874, had a sudden 
attack of left hemi-numbness — face and body. There was only very slight 
loss of motor power, if any. The sensation, which for a long time was in- 
tense, was a mixture of hyperesthesia and numbness. Special senses un- 
affected. The paresthesia has diminished in extent and intensity, but is still 
constantly present in the ulnar side of the left hand and outer side of left 
leg; occasionally in left check. 

Examination shows no actual paralysis, though there is awkwardness of the 
numb parts. There is no true anesthesia, and neither ataxia nor chorea. The 
heart is large and beats heavily; no murmur (?). Has had several angina-like 
attacks. Patient adds, that when first attacked in 1874, his left external 
rectus was paralyzed for two weeks. There is well-marked dementia, slow- 
ness of intellect, and loss of memory. Patient has failed in his examination 
for promotion, in spite of hard work. 

Habits always good ; ])Ositively and repeatedly denies syphilitic infection, 
or any symptoms. Notwithstanding my faith in the doctor's denial, I gave 
him iodide of potassium freely, and in a few weeks all the paresthesia disap- 
peared. Subsequently the case developed into one of dementia paralytica, 
w r ith occasional epileptiform and apoplectiform attacks. He still lives in a 
subjectively happy imbecile state. 

I regret that the notes of the case contain no record of the doses of iodide 
employed. The relief was striking, however. 

Case II. — Paralysis of third cerebral nerves; paresis and ataxia oflimls; relief 



586 POTASSIUM IODIDE IN NO N- SYPHILITIC DISEASES. 

in two attacks ly iodide of potassium. W. R. B., set. twenty-nine years. Re- 
ferred by Dr. Agnew, July 16, 1878. 

Former health poor. Tobacco and beer used to excess ; intense dyspepsia, 
with cardiac disorder and abdominal paresthesia ; catarrh of bladder; im- 
paired memory. Positively denies syphilis. 

July 2d. — While camping in the woods, awoke with paresis of left third 
nerve (ptosis and diplopia), which rapidly became complete paralysis. No 
other symptoms. Galvanism and iodide were employed, and strychnia hypo- 
dermically. 

July 20th. — In last two or three days a numbish feeling began in feet and 
has extended to middle of the thighs ; legs weak ; aching pains from sacrum 
to feet. At times finger tips are also numb. No vesical weakness. No 
patellar tendon-reflex. Was ordered, Squibb's fluid extract of ergot, dry cups 
to spinal region, and rest in bed. Optic nerves normal. 

About the beginning of August the right third nerve also became paretic, 
and then paralytic symptoms in legs and arms were the same ; they were all 
signs indicating a lesion involving the crura cerebri. Ergot was continued, 
and iodide of potassium added to the treatment. 

August 27th. — Very much improved; walks quite well; arms seem weak to 
patient, but he can squeeze 59° with right and 53° with left hand. Both third 
nerves better ; images nearer together ; less dizziness. Has been taking more 
iodide and less ergot of late. Uses galvanic current to hands and eyes. Or- 
dered : cease ergot and increase iodide from present dose of forty-five to sixty 
drops three times a day. 

31st. — Improving. Right internal rectus nearly normal; can open left eye 
better. At times a trifle of numbness in outer part of feet. In spite of sixty 
drops of solution of iodide three times a day his digestion is better than for a 
long time. To continue iodide, and to take 4. of dialyzed iron at bedtime. 

September 7th. — Right eye moves normally; left nearly well; internus and 
levator palpebral are Aveak. Ordered : Continue sixty drops of the solution 
of the iodide t. i. d. [also other remedies for nervousness]. 

12th. — Goes to the country nearly well; left third nerve still paretic. 
Iodide to be decreased by two drops each day. Galvanic application to be 
kept up to the eye. Takes also quinine, iron, digitalis. 

23d. — Advised by letter to resume sixty drops of solution of the iodide. 

December 11th. — Patient was in statu quo ; free from paralytic symptoms 
except in distribution of left third nerve. Is now taking thirty drops three 
times a day. Also bichloride of mercury .004, in elixir of calisaya, three times 
a day. 

During the spring and summer of 1879, the left third nerve varied in its 
condition, and the dosage of iodide was varied accordingly, ranging from 
twenty to sixty drops t. i. d. He had it most of the time, and it never pro- 
duced any disagreeable effect. There was no return of paretic symptoms in 
the limbs. 

Nov. 7, 1879, Mr. B. again came under observation. The left eye was as 
before, and he had some new symptoms. Slight numbness in the deep and 
superficial branches of the left trigeminus (including tongue). Two or three 



POTASSIUM IODIDE IN NON-SYPHILITIC DISEASES. 587 

weeks ago the legs were weak, and an approach to numbness was observed in 
the thighs. 

Examination showed paresis of left third nerve ; when right eye is kept 
closed, and a strong effort of 'the will made, the left lid can be raised, and 
even the internus contracts (slow conduction in nerve). In accommodation 
with convergence the left pupil contracts like the right. Left facial muscles 
are perhaps weak ; the aesthesiometer shows some anaesthesia in distribution 
of the left trigemiuus; pricking is well felt. Tongue projects straight. 
Hands not anaesthetic or numb ; grasp, R., 69° and 64° ; L., 57° and 56°. 
Knee reflex entirely absent. Stands well with eyes closed. Sexual debility; 
optic nerves normal; denies fulgurating pains, and again denies syphilitic 
infection or symptoms. Last winter his wife was delivered of a very healthy 
baby. Ordered : Increase iodide solution from present dose of thirty drops 
t. i. d. by 5 drops each day, to 120 drops t. i. d., then to decrease. Also 
ordered phosphide of zinc, .006; ext. nucis vomica?, .02; quiniae sulph., .10; in 
a pill t» i. d. Goes home to Central New York. 

Oct. 2d, 1880. Returns to New York. Mr. B. carried out the above treat- 
ment faithfully for along time, and was entirely relieA'ed of all symptoms, 
except sluggishness of the left third nerve. He remained fairly well until 
June of this year. Then, after resuming the free use of beer and tobacco 
(denied sexual excess), he noticed awkwardness and numbness of the hands, 
staggering in walking, and legs seemed weak. No change in left eye. Return 
this autumn of numbness in left supra-orbital region. No headache. 

Examination showed a titubating and coarsely ataxic walk; staggering 
when standing with eyes closed ; no patellar reflex; marked anaesthesia and 
ataxia of both hands, especially of right. Left eye as described above (im- 
perfect and slow conduction in third nerve). Pupils active; optic nerves 
normal. The ataxia of hands in test with closed eyes is typical. Slight 
anaesthesia of left forehead. 

The patient remained under treatment until April, 1881, when he went 
home without improvement; really more ataxic and anaesthetic in hands and 
feet. 

Throughout the long duration of the case, there was no headache (only 
paraesthesia at vertex when anaemic in first winter of treatment), and the optic 
nerves have escaped injury. All the symptoms ]wint to disease of the left 
crus cerebri, extending over toward the right, and the case bears a certain 
resemblance to Cases I. and III. of the first group, in which tumors w T ere 
found, except that the patients had blindness from disease of the optic 
nerve. 

I should add that in the last visit of the patient to town, from October, 
1880, to April, 1881, persevering attempts at treatment w 7 ere made. He had 
the iodide solution carried up to 175 drops three times a day; bichloride of 
mercury in moderate doses ; strychina; the actual cautery behind ears and 
dow r n the spine, and galvanism. The disease made slow but sure progress 
all the time. Yet, twice before, in 1878 and in 1879, the iodide had, in the 
most evident manner, removed all symptoms except the paresis of the third 
nerve on the left side. 



588 POTASSIUM IODIDE IN NON-SYPHILITIC DISEASES. 

My friend, Dr. Charles McBurney, who is known to many of you, had been 
Well acquainted with Mr. B., and was disposed to place reliance in his denial 
of syphilis. 

Case III. — Bight hemi-epilepsy and aphasia cured by iodide of potassium. Mr. 
J. L. C, act. twenty-four (?), was seen September 30, 1879. This gentleman was 
brought from Newport by Dr. George Engs, and was placed under my care 
by his family. When I first saw him he was conscious, but suffering from 
frequently repeated epileptiform attacks in the right face. From a variety 
of sources the following history of the case was gradually obtained. Patient 
is a large, well-developed young man, who has always enjoyed good health. 
For more than a year Mr. C. lias worried about some secret trouble, and has 
become dull, complained of insomnia, has lost his interest in reading and in 
music, of which he was very fond. Last winter he contracted a severe 
bronchitis, which has very slowly passed away. No injury to head ; positively 
denies syphilis, and bears no sign of it. 

About the last of August he came in one day from the beach at Newport, 
and said he had had a sunstroke. No one was with him at the time, so that 
the nature of the attack remains a mystery. It could hardly have been a 
sunstroke, as there were no others in NewiDort that day, and the heat was not 
excessive. Judged by the light of subsequent events, it must have been a first 
epileptiform attack. 

Soon thereafter Mr. C. went to Lenox, Mass., and led an active social life, 
dancing, playing lawn-tennis, etc. Complained of headache on the way to 
Lenox, and while there. While there had three or more epileptiform seizures, 
varying from a "faint" to an attack iii which the right arm was stiff and 
unmanageable. This decided spasm, witnessed by an intelligent layman, 
occurred about September 15th. The next day he w r eftt alone to Boston, 
turned up at a friend's club greatly confused, asking who he was, and writing 
his name on a card for use in case of trouble ; came to Newport in a couple of 
days, and was there under Dr. Engs' observation. When seen on September 
— was confused ; used wrong words, or rather had to struggle to find or 
enunciate the right word (aphasia). 

On September 23d, in Dr. Engs' presence, after struggling to find a word, 
he was seized with a full epileptic fit, probably stronger on right side. He 
bit his tongue slightly. Pulse slow, no fever; no albumen in the urine. 
September 24th, epileptic attack in evening. Dr. S. Weir Mitchell saw 
patient ; found optic nerves normal, and would make no diagnosis. Was given 
bromide of potassium in doses of 1.2, frequently repeated. On 25th had 
three or four attacks, chiefly affecting right face, arm and leg. Since he 
has had innumerable partial attacks every day, affecting the right face and 
arm; not always with loss of consciousness. For' example, on September 28th 
he had at least twenty-five seizures ; more frequent in last forty-eight hours. In 
the last day or two the spasm has tended to restrict itself to the face on right 
side, and lias not been accompanied by insensibility. During the week there 
has been progressive abolition of speech ; now says but two or three words. 
Has had from 8. to 10. of bromide of potassium daily in last three to four days. 

Description of facial hemi-spasm, as observed frequently on September 30th 
and on October 1st: "First there is a tonic spasm of superficial muscles, 



POTASSIUM IODIDE IN NON-SYPHILITIC DISEASES. 589 

especially the buccinator and levator anguli oris; the mouth is strongly 
drawn to the right ; eyes closed ; at same time jaws are motionless, some- 
times closed, sometimes opened about thirty mm. In a few seconds clonic 
movements appear in superficial facial muscles, a few chewing movements are 
made, and a stream of saliva flows, partly caught upon a cloth held by patient, 
who is perfectly conscious. Some saliva runs back into the larynx and causes 
cough. Pupils remain normal. A few times the cervical muscles on right 
side seemed stiffened ; tongue not bitten, but a right canine tooth has caused 
ulceration of inside of lip." These attacks were the residua of the previous 
hemi-spasms, and of the still older general spasm. They presented all the 
characters of the Jacksonian or motorial epilepsy, which is so certain an 
indication of a gross local cerebral lesion. 

Oct. 1st. — In the night Mr. C. had from thirty to forty attacks of mixed 
facial and trigeminal spasms on the right side. Arose, and turned down the 
gas, saying distinctly, "Down, down.-' Liquid food causes strangling and 
coughing. Has gone to water closet himself. Axillary temperature normal 
and pulse 90. Last evening was cupped behind ears, and had chloral besides 
bromide: .30 of chloral and 1.20 of bromide every four hours. At noon said 
"beef tea"; looks dull and sleepy, great drewling, tongue protrudes to the 
right; toward evening fewer spasms; pronounces his name on demand; mind 
clear; small blisters behind each ear; no evident paralysis of face, arm, or 
leg, but aphasia and agraphia are practically complete. Patient has the 
vacant, helpless, impatient look of aphasics when asked a question. Pulse 100. 

Oct. 2d. — Very much better. Slept a great deal, and had few spasms 
in face last night ; drinks more easily ; sits naturally on lounge and shakes 
hands; with slowness says about a dozen words; no headache; recalls names of 
Drs. Engs and Mitchell. For the first time in forty-eight hours no spasm occurs 
during my visit; axillary temperature 3G.4° C. ; pulse 102. Less drewling; 
tongue still goes to right ; order 20 drops of a saturated solution of iodide of 
potassium, .30 of chloral, and 3. of bromide at one dose, three times a day. 
The optic nerves were examined in the first few days of the treatment and 
afterward, but found healthy. 

It is unnecessary to continue a journal of this case. The above mixture 
was continued for several weeks, the bromide being reduced to 2. and the 
iodide increased to 80 drops, three times a day. After October 17th no 
chloral was given. The iodide was further increased, a maximum being 
reached on October 26th, when 120 drops were given, with 2. of bromide 
three times a day. 

Not many days later the bromide was omitted and the iodide given with a 
tonic in doses ranging from 100 to 50 drops three times a day. 

At no time did the iodide produce any unpleasant effects. Toward the end 
of October some bromism appeared. 

The improvement was steady in all these four weeks; the local spasms 
became fewer, and ceased before the end of the month. Speech steadily 
increased, and toward the end of the month writing was begun. 

Mr. C. came to see me about getting married last winter. I again questioned 
him about syphilis, and he gave me his word of honor that he had never had 
a venereal sore or a suspicious symptom. 

He has remained perfectly well. 



590 PO TASSIVM IODIDE IN NON-S YPHILITIC DISEASES. 



SECOND GROUP, CLASS B. 

Cases of double optic neuritis, probably due to basal menin- 
gitis, in children ; apparent good results from large doses of 
iodide of potassium.* 

Casb I. — A little girl, aged six years, was brought to niy class at the Man- 
hattan Hospital a couple of weeks ago, with the following simple history; 
For two or three weeks she had complained of headache, had vomited fre- 
quently, and on February 9th (a week ago) internal strabismus appeared. The 
patient has not complained of impairment of vision ; she has not had fever, 
spasm, or delirium. Constipation has, however, been marked. She is anscmic 
looking; a small brother of hers probably has phthisis, and one child of 
the same parents is said to have died of "brain fever." My assistant at the 
Manhattan Hospital, Dr. Adam, immediately examined the child's eyes with 
the ophthalmoscope, and found double neuro-retinitis ; a diagnosis which I 
concurred in, and which was verified by Dr. Webster in the Ophthalmic 
Department of the hospital. Consequently, the most important symptom was 
the one revealed to us by the use of the ophthalmoscope. I made the 
diagnosis of basal meningitis localized about the chiasm of the optic nerves, 
probably without tubercular deposit. The child was blistered behind the 
ears, and given .60 of potassium iodide three times a day, with instruction 
to increase the dose by .30 per dose, every second day. 

The child now does not seem sick, and were it not for the convergent 
squint, one would probably consider her as only a delicate anaemic child. In 
the last few days, the headache and vomiting have ceased, and improvement 
has begun. 

Case II. — Referred for examination to Prof. H. Knapp, on May 2, 1877, a 
girl, aged four years, previously healthy. First symptoms noticed about five 
weeks before examination, consisting chiefly in dullness, irritability, slight 
headache, and, on one occasion only, vomiting. Two weeks later internal 
strabismus (one eye) suddenly set in, and has persisted. No fever, spasm, or 
delirium. Previous to this attack there had been no emaciation, or cough, or 
ill-health of any kind. Dr. Knapp found double neuro-retinitis, with paresis 
of external rectus of one eye. On examination, I found the child with the 
above optic symptoms, and very cross; the buccal temperature was 37.25° C, 
and the pulse 96, perfectly regular. I made the diagnosis of non-tubercular 
localized basal meningitis, and expressed the opinion that the child's life was 
in no danger, though vision might remain considerably impaired. Dr. Knapp 
was giving potassium iodide, which I also advised. A few days ago Dr. 
Knapp informed me that a few weeks after I saw the child the strabismus 
disappeared, and that the neuro-retinitis gradually gave place to atrophy of 
the optic nerves, which, fortunately, was but slight, so that vision is now 
nearly perfect. 

Case III. — A little girl aged five years" was sent to me for examination by 

* From a clinical lecture delivered at the College of Physicians and Surgeons, 
New York, Saturday, February 23, 1878. 



POTASSIUM IODIDE IN NON-SYPHILITIC DISEASES. 591 

Prof. C. R. Agnew, February 14, 1878. I learned that the child had passed 
through an attack of chicken-pox early in January, without fever or apparent 
ill-health. About January 19th, the left eye "turned in," and strabismus has 
been constantly present since. No other symptoms have been observed — uo 
fever, headache, irritability, etc. The mother states that one of her former 
children, at the age of eleven months, had convulsions and fever, became 
unconscious, and died in two weeks. 

Examination of the eyes by Dr, Agnew reveals "double optic neuritis, with 
some stuffing of the disks ; hypermetropia, 5. of the disk. " 

I made the same diagnosis as in the case sent me by Dr. Knapp (Case II.); 
viz., local basal meningitis of a non-tubercular nature. I advised blisters 
behind the ears, and large doses of potassium iodide. The case did very 
well. 

I submit this contribution, well aware of several objections to 
the thesis it supports. 

It may be said that the improvement observed was the 
result of the so-called vis medicatrix naturce, a spontaneous im- 
provement. This might more especially be said with reference 
to the cases of infantile basal meningitis and optic neuritis. 
Case I. of the first group is likewise open to this objection, but 
in the other cases it is different. In Case II. relief was twice ob- 
tained in an evident manner from the iodide ; in Case III. threat- 
ening symptoms repeatedly passed away within a few hours 
after giving full doses of the drug. 

The first class of the second group is more demonstrative of 
the curative powers of the iodide. In Case I. we see hemi-paraes- 
thesia of three years' standing disappearing in a few weeks ; in 
Case II. symptoms quite positively indicative of organic disease 
of the crura cerebri twice relieved (all but slight weakness of 
the third cerebral nerve) by the iodide ; and in Case III. the 
symptom-group which we often call Jacksonian hemi-epilepsy, 
with aphasia, was completely and permanently cured. My expe- 
rience with these hemi-symptoms is, that they nearly always in- 
dicate a tumor in the brain, and I have seldom seen them cured. 

To the cured cases it may be objected that the patients con- 
sciously or unconsciously deceived me as to the existence of 
syphilis. It so happens that the subjects of the class just 
referred to were men who by their temperament and their 
relations to me would have been very unlikely to deceive, and 
they all three were told how essential it was to a proper treat- 
ment of the case that they should tell the exact truth. 

But there are other tests, besides a belief in the truthfulness 



592 POTASSIUM IODIDE IN NOW-SYPHILITIC DISEASES. 

of the patients. They bore no external evidences of syphilis in 
the shape of scars or enlarged glands. Case II. demonstrated the 
non-syphilitic nature of its lesion by a third relapse with new 
symptoms utterly resisting the iodide. Case III. has remained 
well for two years without treatment. 

Case I. had symptoms of failing mind when he consulted me, 
and has since been a good example of paralytic dementia with- 
out positively exalted notions. The non-syphilitic nature of 
this dementia has been shown by its very slow development, and 
by the fact that one or two trials of mercury and iodide of 
potassium proved unfavorable. Besides, the patient, as a 
physician and an army man, was the least likely of all to deceive 
me as to the origin of his trouble. 

In my first experience with these cases, I gave the iodide of 
potassium in medium doses, from thirty to fifty drops of a 
saturated solution three times a day, but since 1877-8 I have 
used much larger doses and with no unpleasant results. 

It is surprising how well patients of all ages bear doses of 
from fifty to one hundred and fifty drops of the solution without 
iodism or gastric catarrh. I give it largely diluted, in from one- 
half to a full tumbler of water, and always on an empty stomach, 
to diminish the risk of decomposition. In the last two or three 
years I have adopted a plan which I think further assists 
immediate absorption of the iodide as such, viz., the use of 
Vichy instead of common water as a vehicle ; or, as a substitute 
for poor patients, a solution of bicarbonate of sodium. I might 
add that in several patients, including one of those referred to 
in this paper (Case II. of second group), digestion has been im- 
proved by the iodide given in this way. 

Even if the iodide of potassium cannot cure organic diseases 
of the brain it seems to relieve symptoms. If by the free use of 
such a remedy, one not directly harmful, we can diminish intra- 
cranial tension, remove oedema, or perhaps check the growth of 
some neoplasm, thereby relieving pain and other distressing 
symptoms, would not this be a gain to our therapeutics ? 

IDEAS OF DIFFERENT AUTHORS BEARING ON THE SUBJECT OF THE 

FOREGOING PAPER. 

Bartholow, E., A Practical Treatise on Materia Mcdica and Therapeutics, 
3d edition, 1880, p. 191, says: "But few affections of the brain, non-specific 
in origin, are benefited by the iodides." 



POTASSIUM IODIDE IN NON-SYPHILITIC DISEASES. 593 

Bartholow, R., A Treatise on the Practice of Medicine for the Use of 
Students and Practitioners, 3d edition, 1882, p. 568, in speaking of the treat- 
ment of intra-cranial tumors, says: "There are two remedies which ought 
always to be used — iodide of potassium and ergot ; for although only syphil- 
itic and possibly aneurismal tumors* are remediable, the case under treatment 
may be one of them." 

Edes, Robert T., Therapeutic Hand-book of the United States Pharmaco- 
poeia, etc., 1883, p. 255, says: "The curability of any disease by iodide of po- 
tassium, however, does not warrant a diagnosis of syphilis." Page 256: "It 
should be given freely in all cases of cerebral tumors, and often in meningitis." 

Flint, Austin, A Treatise on the Principles and Practice of Medicine, etc., 
5th edition, 1881, p. 726, when speaking of the treatment of tumors within 
the cranium, says: "It is, however, claimed, that certain remedies, namely, 
the iodide of potassium, the bichloride of mercury, and arsenic do have such 
an influence in such cases " (meaning non-syphilitic growths). 

Hamilton, Allan McLane, Nervous Diseases; their Description and Treat- 
ment, 1878, p. 202, under the treatment of tumors of the brain, says: " It has 
been my practice in every case to place the patient upon an anti-syphilitic 
course of treatment." 

Hammond, William A., A Treatise on the Diseases of the Nervous System, 
7th edition, 1881, p. 324, under the head of treatment of tumors of the brain, 
says: " So far, however, as other* tumors of the brain arc concerned, there is 
no treatment calculated to cure the patient, unless a syphilitic taint can be 
ascertained to exist. It is well, however, even when there are no positive 
indications of the presence of such a diathesis, to act upon the presumption 
that it docs exist, and to administer mercury in some form with the iodide of 
potassium." 

Obernier, F., in Ziemssen's Cyclopaedia of the Practice of Medicine, vol. 
xii., Diseases of the Brain and its Membranes, when giving the treatment of 
tumors of the brain and its membranes, p. 288, says: " A trial of itf should 
not be neglected." 

Ross, James, A Treatise on the Diseases of the Nervous System, 1881, vol. 
ii., p. 567, when giving the treatment of focal diseases of the brain, says: 
"With the view of promoting absorption of the morbid growth, iodide of 
potassium has been administered in large doses and with apparent benefit." 

Stille and Maisch, The National Dispensatory, 2d edition, 1879, p. 1161, 
under the subject of potassium iodide, say: "In many cases of paralysis, due, 
probably, to pressure upon a motor centre, or upon a nervous trunk, produced 
by syphilitic or other swellings, the medicine is often singularly efficient and 
should never be omitted from the treatment." 

Wilks, Samuel, Lectures on Diseases of the Nervous System, 1878, p. 461, 
in general remarks on remedies, says : "In cases of epilepsy and many obscure 
nervous affections, I usually commence with this class of remedies, % knowing 
that a curable disease has sometimes ended fatally because they have been 
overlooked."— [R. W. A.] 

* Meaning other than aneurismal. f Meaning iodide of potassium. 

\ Meaning iodide of potassium and perchloride of mercury. 



ON THE EFFICIENT DOSAGE OF CEETAIN EEMEDIES 
USED IN THE TEEATMENT OF NEEVOUS DIS- 
EASES.* 

Me. President and Gentlemen : I have been led to prepare 
this paper by the following consideration. I frequently see 
uncured cases of nervous disease for which the attending physi- 
cian has prescribed the proper remedy, but having exhibited it 
in doses which, though justified by medical authorities, were 
wholly insufficient to influence the disease, he has failed. This 
has been 1 more especially true of chorea, of cerebral and spinal 
syphilis, of certain neuralgias. In these cases the physician 
had been wanting in the experience and in the courage necessary 
to fight his way through opposing tradition and book-authority 
to success. 

There are several evident causes for this timidity, which in a 
negative way is nearly as injurious to the patient as too great 
rashness would be. 

In the first place, the influence of teachers in medical schools 
and of writers of text-books is thrown in favor of small or 
medium doses. Few if any teachers or writers take special pains 
to indicate the maximal doses of potent drugs ; they teach in a 
condensed form, and with an eye to the safe training of students. 
This is very well as applied to students, but a time comes when a 
physician in active practice wants to know just how much physi- 
ological effect he can obtain with certain remedies without posi- 
tively endangering his patients' lives. In the present state of 
our medical literature, unless he have time and opportunity to 
hunt through the files of the leading medical journals for detailed 
observations, or to read monographs on experimental therapeu- 
tics, he must work out his maximal doses for himself at the cost 
of much time, of some anxiety, and of not a few failures. 

It seems to me that works on therapeutics intended for the 
practitioner should give, for each important, physiologically 

* Read before the Medical Society of the State of New York, Feb. 7, 1882. 
Reprinted from the Archives of Medicine, vol. vii., No. 2, April, 1882. 



EFFICIENT DOSAGE IN NERVOUS DISEASES. 595 

active remedy, a paragraph on maximal doses, clearly indicat- 
ing the amounts necessary to produce the physiological effects 
(on man), which are often inseparable from remedial effect. 
These data should be taken from monographs and special 
articles on the subjects by men who have had experience in the 
use of the drugs mentioned. For I take it as granted that it is 
now just as impossible for one man to give us a satisfactory, 
practical work on therapeutics, as it is for one to produce a 
uniformly excellent work on the practice of medicine. 

In the second place, I have observed that many capable drug- 
gists are alarmed at doses of certain remedies which are not only 
harmless, but essential to success. I clearly remember that, 
when a student, I heard the late Prof. Freeman J. Bum stead 
relate, with a mixture of amusement and anger, how a leading 
druggist had sent to him to inquire if he really meant to give 6. 
of bromide of potassium at one dose. This was twenty years 
ago. Yet, only a few days since, a patient told me that her 
druggist told her that she must have a very strong stomach to 
stand such powerful medicine (she was taking .004 of binio- 
dide of mercury and 3. of iodide of potassium three times a 
day, and under this in one week had lost nearly all her syphilitic 
pain). Yery frequently have I had prescriptions for my usual 
doses of Squibb's conium returned for revision by the careful 
pharmacist. I intend nothing derogatory by these remarks, for 
druggists are supposed to know only the maximal doses of 
remedies as given by books, and they but do their duty in send- 
ing a prescription back for revision, if anything in it seems 
wrong; for my part, acknowledging a liability to error, I am 
always glad to see this healthy doubt applied occasionally to my 
prescriptions ; yet I would not have physicians allow themselves 
to be influenced by the remarks or practice of druggists. Philo- 
sophically, the two professions are absolutely separated ; the 
one furnishes the other with the proper implements of treatment 
in the best possible condition ; and it is the function of the 
physician to determine by scientific knowledge and by expe- 
rience how, when, and how much these implements shall be 
employed. In more senses than one the physician is respon- 
sible for the dosage of remedies. 

In the third place, it has seemed to me that our large manu- 
facturing drug-firms exert a baneful influence upon therapeutics. 
They have flooded the country with formulas and ready-made 



596 EFFICIENT DOSAGE IN NERVOUS DISEASES. 

compounds, and thus relieved the physician of the necessity of 
exerting his power to extemporaneously devise the compound 
required for the individual patient before him. Increasing num- 
bers of physicians, instead of adapting the materia medica to 
their patients, practically adapt their patients to an already 
prepared stock of elixirs, pills, and mixtures. It is so conven- 
ient to order one of these, so much easier than to weigh the 
indications presented by the case, to estimate the patient's sus- 
ceptibility, and then to write out a good prescription for the 
case, or more exactly speaking, for the patient. 

I' propose to review briefly the posology of a few drugs — 
giving the doses as stated by the best authorities, by writers on 
therapeutics, and by clinicians, and then stating the doses which 
I believe to be useful and safe. 

I wish it particularly understood that in advocating larger 
doses of these remedies I do so only on the basis of a tolerably 
large experience, and not at all from any theoretical scientific 
considerations. At the same time that I advocate efficient 
doses, I am carefully observant of all the circumstances which 
render patients susceptible, and always make an allowance for 
idiosyncrasy. Thus, in first prescribing a potent remedy, I take 
into consideration the age, sex, and size of the patient; and also 
make an estimate of his general condition, and note particularly 
the state of his circulatory organs. Then, for a patient whom I 
see for the first time, I order very small doses, doses such as 
the books justify, and by steady increase feel my way, fearlessly 
because watchfully, to the larger doses, often seemingly danger- 
ous doses, which really affect the organism and may cure the 
disease. 

In this matter I make no claim to originality, and would not 
affirm that the doses I recommend are always essential to suc- 
cess ; I simply sum up my experience and place my results at 
your service. 

I. — Fluid Exteact of Conium. 

{Exir actum conii frudtis fluidum.—TJ. S. P.) 

Doses as given by authorities on therapeutics and materia 
medica : 

Is not mentioned by Stille* and Maish, by Stille", by Noth- 
nagel, nor by Gublee. 



EFFICIENT DOSAGE IN NERVOUS DISEASES. 597 

Wood. Therapeutics (1880), p. 371. Dose, .06-.10. 

Baktholow. Materia Medica (1880), p. 409. Pose, .12-.30, 
increased to 2.4. 

Eice. Posological Tables (1879), p. 28. Dose, from .18-.30, 
to be increased with caution. 

Doses as given by clinicians : 

Conium, in the form of fluid extract, is not, to my knowledge, 
mentioned by any standard writer on the practice of medicine. 

Meigs and Pepper, Diseases of Children (1870), p. 565, article 
chorea, refer to Dr. J. Harley's doses of succus conii with appar- 
ent astonishment. 

To Dr. John Harley (The Old Vegetable Neurotics, London, 
1867) we owe the present rational or physiological use of conium. 
He swept away the former traditions of the potency of the drug, 
and showed that most of its preparations were inert. He obtained 
definite physiological and therapeutical results from the succus 
conii, administered in doses of from 8. to 32. By means of these 
quantities he obtained the paresis of third nerves, arms and 
legs, which is the characteristic result of conium action on the 
spinal cord. 

The prototype of our excellent officinal preparation, the fluid 
extract made by Dr. Squibb, was unknown to Dr. Harley until 
just as his book was going to the press (p. 94, note). 

Dr. Squibb and Dr. Manlius Smith had, however, read a paper 
before this Society, at its meeting in 1867, entitled : " An attempt 
to answer the question, Which part of conium is the best for 
medicinal use ? " (See Transactions of the New York State 
Medical Society for 1867.) 

Ever since, we, on this side of the Atlantic, have possessed 
by far the most reliable and the most powerful preparation of 
conium ; but I am sorry to add that it has been used rather 
inefficiently, and that even intelligent physicians are afraid to 
use the only doses which have any effect. 

I have used conium a good deal in the last ten years, and have 
always employed the fluid extract as made by Squibb. I have 
tried it in chorea, in spasm of paralyzed limbs, in general irrita- 
bility, and in insomnia. 

"When the indication is present, as in chorea, to obtain mus- 
cular relaxation, after a few tentative doses of 1.2-2.4, I give at 
one dose 4.-6. cc. These doses cause drooping of the upper 
lids (sometimes diplopia) and paresis of the arms and legs. I 



598 EFFICIENT DOSAGE IN NERVOUS DISEASES. 

do not repeat the dose until after all the effects have passed off 
- — in from 12 to 24 hours. 

In a case of chronic, adult chorea of 14 years' standing, which 
I almost perfectly cured in 1872-3, at the Epileptic and Para- 
lytic Hospital on Blackwell's Island, a large part of the result (a 
very remarkable result in my experience) was attributable to 
paresis daily produced by a teaspoonful of Squibb's extract of 
conium for a month or more. 

Many cases of insomnia, with wakefulness in the first part of 
the night, more especially those with fidgets or physical rest- 
lessness, are very much benefited by conium. I usually give 
lo2 cc, with 1.2 of bromide of sodium in camphor water, at bed- 
time, to be repeated if necessary. In some cases (male adults) 
I give 3.-6. cc, at one dose in the mixture, not to be repeated. 
Such a sleeping-draught prescription has been repeatedly re- 
turned to me by druggists, because they thought the dose enor- 
mous. Indeed, I usually warn patients that the druggist may 
comment on the dose. 

If we have a clear indication to give conium, we ought to give 
enough to fulfill the indications, and this cannot be done without 
obtaining the physiological effects. With due precaution, there 
is a wide and sure distance between physiological and toxic 
effects, yet, with reference to remedies such as I shall refer to, 
how few physicians understand and appreciate that the curative 
effects are obtained in just that interval between physiological 
and toxic effects. To be successful we must be bold, as bold as 
physiological knowledge can make us, and yet as cautious in the 
first giving of powerful drugs to a patient as if we had no cour- 
age at all. 



ON THE EFFICIENT DOSAGE OF CEKTAIN KEME- 
DIES USED IN THE TEEATMENT OF NEKYOUS 
DISEASES.* 

II. — Crystallized Aconitia of Duquesnel. 
(Aconitia. — U. S. P.) 

Doses as given by authorities on materia medica and thera- 
peutics : 

Stille and Maisch, National Dispensatory (1879), p. 101. 
Primary dose .00024 two or three times a day. It is recom- 
mended in doses of .0005. 

Wood, Therapeutics (1880), p. 180, makes the truly astonishing 
statement that : " The alkaloid is officinal, but, on account of its 
intense activity, should not be given internally." 

This was printed more than a year after the publication of the 
New York Therapeutical Society's report on aconitia in the 
New York Medical Journal for 1878. See also p. 367. 

Bartholow, Materia Medica (1880), p. 44, simply quotes the 
New York Therapeutical Society's formula. No personal state- 
ment as to doses. 

Kice. Posological Tables (1879), p. 5 : " Aconitia ; aconitine. 
Alkaloid from aconite. The commercial product is an impure 
mixture of alkaloids. The dose is .0004 to .0005 increased with 
caution. Chiefly externally." 

Nothnagel and Kossbach. Arzneimittellehre (1878), p. 721. 
Aconitia is little employed internally. Dose, 0.004, and the 
daily quantity as 0.03. 

This cannot refer to Duquesnel's aconitia. It might be a safe 
guide for giving Merck's aconitia, which is very impure and of 
doubtful efficacy. 

Gubler. Lecons de Therapeutique (1877), pp. 147, 8. Prof. 
Gubler may be considered as the introducer of Duquesnel's 
aconitia. In articles, besides in this book, he was the first to 

* This article is a continuation of one which appeared with the same title in tho 
April number of this journal, page 177. — Reprinted from the A rchives of Medicine, 
vol. vii., No. 3, June, 1882. 



600 EFFICIENT DOSAGE IN NERVOUS DISEASES. 

indicate its wonderful efficacy in neuralgia, particularly trigem- 
inal neuralgia. 

He recommends 0.0005, or less at first ; gradually increased 
to 0.002-0.004-0.005. 

Doses recommended by clinicians : 

As Duquesnel's aconitia has been known so few years, and 
has been in use less than four years in this country, it is not 
singular that our principal text-books do not speak of it. Still 
one is surprised to find that Prof. Flint in the last edition of his 
" Practice," dated 1881, does not refer to aconitia among the 
remedies which may cure neuralgia. 

Hammond, Diseases* of the Nervous System (1881), pp. 857-8, 
speaking of the treatment of neuralgia, recommends Duques- 
nel's aconitia in doses of .0005, gradually increased to .0013 if 
necessary, till relief be obtained, or till the characteristic pe- 
ripheral numbness occurs. 

Personal experience. Influenced by Prof. Gubler's article and 
by his books, I began using the aconitia of Duquesnel in the 
winter of 1877-8, with most gratifying results. More of the drug 
was imported, and in a few months several of my friends were 
trying the remedy — among them I may name Dr. McBride and 
Dr. Andrew H. Smith. 

At a meeting of the Therapeutical Society of New York, held 
October 11th, 1878, I presented the report of the Committee on 
Neurotics of that Society upon the use of this aconitia. We 
reported ten cases cured or relieved. This report will be found 
in the New York Medical Journal for December, 1878. See also 
p. 367. 

Since that time aconitia has been used by many physicians in 
numerous cases of trigeminal neuralgia, with very favorable 
results. A large proportion of cases have been cured, and some 
very ancient cases (8 to 12 years) greatly relieved by the medicine. 
A few cases only have been uninfluenced. 

In the last two years the alkaloid has been offered in pillular 
form by several reliable drug-firms, and I can testify to the po- 
tency and reliability of Caswall & Hazard's tablets, and of Schief- 
felin's pills. These firms furnish doses of .0003 and of .0006. 

In my first use of aconitia I employed a solution made by the 
late Dr. "William Neergaard, the only pharmacist who then 
(1877-8) held a sample of Duquesnel's preparation. My formula 
was : 



EFFICIENT DOSAGE IN NERVOUS DISEASES. 601 

B Aconitise (Duquesnel's) - - - - .006 

Glycerinae, 

Spt. villi rect., ------- aa 4. 

Aquse menth. pip., ----- ad 62. 

Each teaspoonful (estimating seven teaspoonfuis to 30. cc) con- 
tained about .0004. This dose was to be given two, three or 
more times a day, on an empty stomach, till the pain ceased or 
the physiological symptom — numbness — was produced. As my 
subject to-day is not clinical therapeutics as much as posology, 
I pass by many interesting facts about the use of aconitia, and 
omit all cases. 

The remark which I have already made about the necessity 
of giving small doses of potent drugs to a patient whom we see 
for the first time, and of estimating his susceptibility, applies 
with especial force to aconitia. Bearing this in mind and carry- 
ing it into practice, we may be very bold, almost rash, later on, 
without running real danger. 

Those of us who introduced aconitia in 1878 soon discovered 
that some persons, females especially, were powerfully affected 
by minute doses. Dr. A. H. Smith reported a case to our com- 
mittee in which a lady was distressed by .00016, and I myself, 
while in a reduced state of health and suffering severe trigem- 
inal pain, was severely benumbed by .0003 (though long after- 
ward, when quite well, it required two doses of .0006 to produce 
nearly similar effects). 

It is well, consequently, to give debilitated, susceptible and 
female patients, doses of .00024 or .0003 to begin with. These 
facts have induced the Messrs. Schieffelin & Co. to cease making 
pills of .0006, and to furnish only .0003, pills, which can be re- 
peated at will. Messrs. Caswell- & Hazard still furnish both 
doses in the shape of soluble tablets. 

In a case of neuralgia, after a day's testing with minute doses, 
if I find no undue susceptibility to the drug, I give it freely — 
.0006 every three or four hours until distinct numbness and 
coldness (subjective coldness) be felt in the limbs and face. 
Then a longer interval may be allowed before giving another 
dose. Some subjects will take three or four tablets of .0006 
each day, and be in a constant state of numbness without harm, 
and often with curative effect. 

In some of my cases of chronic epileptiform neuralgia I have 



602 EFFICIENT DOSAGE IN NERVOUS DISEASES. 

kept patients under the influence of the drug for days and weeks, 
- — and have seen no evidence of cumulative effects: 

As a rule, in testing a man of average physical development 
and not reduced by disease I at once start with doses of 0.0006. 

As regards maximal doses, I may state that in certain cases of 
posterior spinal sclerosis with severe fulgurating pains I have 
given from 4 to 8 doses of .0006 each in 24 hours, producing in 
some cases faintness, sickness, and a considerable prostration. 
I might add that this form of nerve pain has never been relieved 
by aconitia, and that with hardly an exception, all the tabetic 
patients I have experimented on have not shown any trace of the 
numbness which is the sign of aconitia effect in healthy persons. 

As a rule, the pain of trigeminal neuralgia ceases when the 
physiological effects of the drug are manifest. I do not pretend, 
and Prof. Gubler did not claim, that aconitia is a certain or 
specific remedy against trigeminal neuralgia, but it certainly is 
the best of all our present therapeutic resources against this 
terrible disease. Of course in certain cases, special etiological 
factors must be considered, and other treatment given besides 
the aconitia : for example, in clearly malarial neuralgia, and in 
syphilitic neuralgia, or in the (rare) neuralgia from bad teeth. 

III. — Phosphokus and Phosphide of Zinc* 
(Phosphorus.— U. S. P.) 

Doses given by authorities on materia medica and therapeutics : 

Stille and Maisch. National Dispensatory (1880), p. 1072. 
These authors, apparently wholly relying upon* Gubler and 
Thompson, state that the dose varies from .003 to .005. They 
say : " Those who have most advocated its use recommend that 
a first dose of .003 should be repeated every four hours till six 
doses are taken. If then no improvement (in neuralgia) have 
occurred, the dose should be increased to 0.005, and repeated in 
the same manner as before." 

They do not, however, mention Thompson's alcoholic solution 
of phosphorus. 

Zinc phosphide (p. 1546) in doses of .004 to .008, and even .02. 

Stille. Therapeutics (1874), vol. i., p. 800. " Moderate doses 
of .0015 to .015." (Phosphorus). 

* The equivalent of zinc phosphide (Zn 3 P 2 ) is 195.6 -f- 62 — 247.6. Consequently- 
one part of the phosphide contains 25 % (about) of phosphorus. 



KMM1UUIT DOHA JM IB WKSVOUE BflZEASHi '■'.: 

:•: : . Therapeutics <1880i p. 113, recommends a mixture con- 
taining olenm phosphoratnm, each dose to contain from .002 to 
.004 ; or of a chloroforrnie solution in a mixture. .004 

I_t lose : sine ph -phide Lr gives m .0006 to .001*2 which 
age contradiction to his full doses of phosphorus. 

Bai.ie i >n Maftmi Medics lflbt p. 96. 

Dose of oleum phosphoratum. U- S. P.. 5 to 10 drops equal 
to .003:: 

fees I _:=t - : :Liula for piL phosphori, .0018 in each 
pilL Also quo:-- Ufa : ■_ - : s tinctura phosphori in doses 
equivalent to .0015 and .003. 

The lose : phosg hide of zino be 15. 

Bkk. Posologieal Tallies I"" leum phosphoratum 

51 . No dose _: vgb Eecommends Dr. SquibVs solution : Phos- 
phc: as 1 .rt : cod-liver oil 99 par:- 

•Phosphorus. .0006 to .003, increased with caution." 

>" : :: ii ZIossbach. ArzneimittellrL:T 1-"- 200. 

Dose from I U 05. 

~p. t ttl Lee u I utique 1877 _ 7. Dose, 

in granules : from 2 to 10 a day. 

I . jises the oleum phosphoratum in capsules. 

Zinc phosphide, from .01 to .<>6 par diem; he ra:L-r lepxe- 
: - - . - - - : . - 

Doses is _ - on clinical me «iicir_- 

Hamm : Diseases : the >-: - - _ >-l 
^king of cerebral congestion, he says that the oleum phos- 
phoratum may be given in a mixture in doses 5 drops. 

Z:_: phosphide, the formula of which he gives as*Ziir P, and 
-s as being one-seventh phosphorus, he recommends 
in .006 dose, in pill form (this gives 1 — :f phosphor - 
the phosphoretted resin may be used to make pills, each con- 
taining .0 1 - of phosphor > 

Bur Practice of Medicine 1881), j Merely names 

phosphorus as a remedy for neuralgia : gives no doses or esti- 
mate of its value. 

Axstie. On Neuralgia 1871 p. 180. States that he has used 
the phosphuretted oil and pills of phosphorus 'Dr. Badclir- - 
containing .002, three times a day. He does not estimate it as 
especially useful T^is was written before the publication of 
XL -_iv~ --_'« — irk. 

J. A«mm rem Thompson. Free Phosphorus in Medicine, Lon- 



604 EFFICIENT DOSAGE IN NERVOUS DISEASES. 

don (1874), p. 190 : " The chief precaution to be observed in the 
treatment of neuralgia with free phosphorus * * * is to 
administer a full dose of the remedy in the first place." 

« * * * unless .03 or more be given in the course of 
each twenty-four hours, frequent failures, or only partial suc- 
cesses in treatment will be met with." " But the remedy must 
be given in not less than this dose, i.e., .005 repeated every four 
hours, from the beginning of treatment." 

Page 191. He admits the utility of the alcoholic and ethereal 
solutions, reduced phosphorus, and even zinc phosphide, but he 
has had the best results from .005 of phosphorus dissolved in 
cod-liver oil, every four hours. 

Thompson has more recently furnished the following formula 
for the preparation of a solution of phosphorus, which is not 
unpalatable to most patients. 
Take of 

Phosphorus, ----- .06 
Absolute alcohol, - 20. 

Dissolve with heat 
Glycerine, - - - - - 48. 
Alcohol, - 8. 

Essence of peppermint, - - 1.2 

Mix the two solutions, which make nearly 80. ; one teaspoon- 
ful = .003. This should be given without water. 

Personal experience. Very soon after the appearance of Dr. 
Thompson's article, I caused this solution of phosphorus to be 
made by Mr. P. Haas, by Caswell, Hazard, & Co., and by the 
late Dr. Neergaard, and used it a great deal. A weaker prepara- 
tion or imitation, under the name of elixir of phosphorus, one 
teaspoonful of which contains .0015 is also sold, but I prefer the 
stronger form, and write for solutio phosphori (Thompson). 

I have employed this solution with the greatest success in 
trigeminal neuralgia, and with some success in other neuralgias 
— following Thompson's plan of giving full doses, usually one 
teaspoonful (about .003, if we estimate a teaspoonful to be about 
4 cc), every 3 or 4 hours. I have known a severe facial neuralgia 
(not chronic epileptiform neuralgia) cured in two days, and even 
in 24 hours ; several cases, in a week. 

In conditions of nervous prostration, cerebral anaemia, incipi- 
ent cortical degeneration (dementia), in melancholia, I have been 



EFFICIENT DOSAGE IN NERVOUS DISEASES. 605 

much pleased with a combination of Thompson's solution and 
cod-liver oil in the proportions of 1 : 6 or 1 : 4, a teaspoonful of 
the mixture being given after each meal. 

In other cases I have had an extemporaneous mixture made and 
given two or three times a day : Thompson's solution, 1 tea- 
spoonful ; sherry, 2 tablespoonfuls ; cod-liver oil, from 1 to 2 table- 
spoonfuls ; and the yolk of one egg, thoroughly beaten and mixed, 
with the addition of a little extra oil of peppermint. This is 
well received by most patients, and constitutes a most valuable 
tonic. 

The phosphide of zinc in doses of .01 to .015 combined with 
nux vomica or with belladonna, according to indications, has 
seemed of some efficacy in the treatment of posterior spinal 
sclerosis, of cerebral anaemia, of nervous prostration (" neuras- 
thenia "), and of incipient dementia. 

With pills of pure phosphorus, I have had little experience. 
The pills offered by most of our manufacturing drug concerns 
are of too small a dosage. As may be seen from the citations 
made, and from my own experience with other preparations, the 
giving of .0006, or even of .0012, of phosphorus is of probably 
very little use. From .002-003 should be administered three 
times a day, with, of course, due watchfulness for signs of gas- 
tric irritation. 

IY. — Crystallized Nitrate of Silver. 
(Argenti nitras. — U. S. P.) 

Doses as given by authorities on materia medica and thera- 
peutics : 

Stille and Maisch. National Dispensatory (1880), p. 237. 

Dose from .01 to .015 three times a day. Doses of .03 occasion 
no special symptoms, but larger quantities are apt to cause gas- 
tric heat, pain and nausea. 

Stille. Therapeutics (1874), i., p. 367, et seq. 

Quoting authors upon diseases of the nervous system he 
refers to doses varying from .01 to .015, three times a day. 

"Wood. Therapeutics (1880), pp. 51-3. 

Dose from .015 to .03, in pill form, given upon an empty 
stomach, when it is desired to affect the stomach, and after 
meals, when the constitutional effects of the drug are desired. 

" "When given for a chronic disease, its administration should 



606 EFFICIENT DOSAGE IN NERVOUS DISEASES. 

be suspended for one week, at the end of every third week, 
and its employment should not extend over a longer time than 
three months, without a protracted intermission." 

Baetholow. Therapeutics (1880), pp. 213-5. 

Gives elaborate directions and formulas for its use in various 
visceral affections, dyspepsia, gastritis, colitis, etc., but hardly 
refers to its use in nervous diseases, and does not recommend it. 

Eice. Posological Tables (1879). 

Dose .015 to .12 ; increased with caution. 

Nothnagel and Eossbach. Arzneimittellehre (1878), p. 113. 

In pill form, .005-. 03. 

Gublee. Lecons de Therapeutique (1877), p. 579. 

Thinks that no good effects are to be expected from its inter- 
nal use, and gives no doses. 

Doses as given by authorities on clinical medicine : 

The older English physicians, Sims, Wilson, Harrison, and 
Boget, quoted by Stille, Therapeutics, i., p. 367, gave doses of 
.06-36, three times a day, for epilepsy. It is not now employed 
for this disease I believe. 

Flint. Practice of Medicine (1881), p. 476. 

Speaking of locomotor ataxia, he recommends giving from .01 
to .02, three times a day, for several weeks ; then suspending 
its use for a while. 

Hammond. Diseases of the Nervous System (1881), p. 633. 

In the treatment of locomotor ataxia, merely mentions dose 
of .015 three times a day ; gives no details, and does not seem to 
attach any value to the drug. 

Wunjdeelich, Archiv der Heilkunde, 1861, ii., p. 193 (cited by 
Stille, p. 368), gave .012 twice and thrice a day ; quoted by 
Topinaed, he gave .01 three or four times a day ; for locomotor 
ataxia. 

Bouchut (cited by Stille, pp. 368, 9), Bull, de Therap., lxiv., 
p. 57, gave to a child five years old, with paraplegia, .006 twice 
a day. To adults for paralysis from .024 to .06 a day. 

Topinaed, De l'ataxie locomotrice, Paris, 1864, pp. 435-468, 
gives a full account of the attempts to cure sclerosis of the 
posterior columns by silver ; relates several cases of his own, 
and concludes that the drug is usually useless in locomotor 
ataxia ; he gave from .01 to .09 per diem. 

He gives the following doses as prescribed by several well- 
known physicians : 



EFFICIENT DOSAGE IN NERVOUS DISEASES. 607 

Chakcot and Vulpian in 1862 gave doses of .01, .02, .03 three 
times a day. Later Charcot has given as high as .08 in a day. 

Pidoux, .OS per diem. 

Gubler and Beau, .10 per diem. 

Hellairet, .15 per diem. 

W. Erb. Ziemssen's Cyclopaedia, Am. ed., vol. xiii. On 
Diseases of the Spinal Cord, pp. 614, 5. Recommends from .01 
to .02 three times a day, or from .06 to .09 per diem, until 8. or 
10. have been consumed. He has a high opinion of the med- 
icine, for he says, p. 614 : " Among the internal remedies for tabes, 
nitrate of silver undoubtedly stands first, as it can show quite 
undoubted results." 

Personal experience. I have employed nitrate of silver 
extensively in the treatment of locomotor ataxia, and am almost 
disposed to agree with Erb. I can most positively assert that 
in quite a number of my cases the course of the disease has been 
materially checked, and in many others repeated periods of 
relief secured by nitrate of silver. 

I have also given it in various forms of subacute and chronic 
myelitis, but with less definite results ; though my impression of 
its action in these cases is favorable, 

I seldom prescribe less than .0125 of silver at a dose, and 
usually give .03. The remedy is made up in a pill with an 
indifferent extract (taraxacum), or with extract of nux vomica, 
or with extract of belladonna, according to the indications of 
the case, whether for spinal stimulation or for sedation. 

I always give the pill before meals, three times a day, and 
occasionally administer a fourth pill at bedtime. A course of 
silver, with me, usually lasts two months, which, at the rate of 
.10 a day, would give 6.— a perfectly safe quantity as regards 
danger of discoloration of the skin. After an interval of two or 
three months I often give another, shorter course, and so on. 

None of my patients has as yet shown discoloration (argyria), 
and I have seldom been annoyed by the occurrence of gastric 
and intestinal irritation. Albuminuria from its use I have 
never seen. 



OASE OF INJUEY TO THE MOTOE AEEA OF THE 
BBAIN, WITH EXHIBITION OF THE PATIENT .* 

Wm. M. G., set. 27, Middletown Springs, Yt. Dr. Middleton 
Goldsmith. Nine years ago struck by a stone just above right 
ear. Was senseless. Patient says he could walk when he 
came to, but could not use left arm ; claims that he could not 
move any portion of arm or hand. Could talk. Not much 
trouble from wound, but at the end became unconscious and had 
a convulsion. 

Dr. Thomas was then called. Was convulsed generally, and 
had a depressed wound above the right ear ; face perhaps a lit- 
tle paralyzed, and leg was a little weak, but the palsy of arm was 
complete. Several repeated spasms ; was bled for convulsions, 
but no operation was performed ; no bone ever came away ; it was 
several months before wound healed. Had other convulsions 
in a week, then very frequently, daily, several a day, sometimes 
a week without attack ; once was three weeks without attack. 
Seizures now quite frequent ; also has petit-mal, and in this 
perhaps the hand is stimsh. No evidence of nocturnal attacks. 

Marked analgesia of hand and fingers, though he says he feels 
contact of objects, and pin going through. 

Hand very athetoid ; was contractured in flexion for quite a 
while after wound, time uncertain ; limber for 4-5 years. 

The man's head exhibits a rounded, saucer-shaped depression 
in the middle of the right parietal bone. The lower edge of the 
cicatrix is eleven centimetres above the apex of the tragus, and 
its upper edge fixe centimetres from the median line. From the 
nasal spine to the anterior edge of the scar is sixteen centimetres. 
The diameter of the depressed area is between three and four 
centimetres, and its greatest apparent depth about eight milli- 
metres. It is firm and bony throughout. Projecting the lines of 
Broca on the head the scar is found just anterior to the Eolandic 
line, overlying the middle of the ascending frontal gyrus. 

The patient was examined by several members, who expressed 

* Read before the American Neurological Association, June 21st, 1882. Ke 
printed from the Journal of Nervous and Mental Disease, 1882. 



CHOKED DISC WITH CEREBRAL TUMOR. 609 

the opinion that the man's epilepsy might be cured by the pro- 
posed operation of trephining. 

The patient was trephined by Dr. H. B. Sands, June 27th, 
1882. From his report * the following notes are taken : 

A nearly circular aperture 4.5-5 cm. in diameter was made. 
Depressed bone was found which was quite vascular and con- 
siderably thickened, being 12 mm. in its thickest part. 

March 25th, 1883, the patient was reported in better con- 
dition, the seizures less violent, headache less intense, and the 
weakness of the right hand less marked. 



KEMAKKS ON THE FKEQUENCY OF HEADACHE AND 
CHOKED DISC WITH TUMOE OF THE BEAIN.f 

With reference to headache I am ready to admit that it is one 
of the important symptoms, and in gome cases that it is almost 
the only symptom ; that it is excruciating and peculiar. It so 
happened, however, that in two of my cases of well-defined 
cortical sarcoma no headache was present. In the first case the 
symptoms began in the leg. There was no headache until one 
night the patient had an apoplectic attack. The lesion was 
situated in the paracentral lobule, and in the tumor there was 
a cyst. There was no headache that could be attributed to the 
sarcoma. In the second case of sarcoma there was no head- 
ache before the appearance of definite symptoms of brain tumor, 
but the patient experienced occipital neuralgia. 

With reference to the neuritis and choked disc, I am obliged 
to confess that I have had a very singular experience. I have 
seen a number of cases of encephalic tumor and a number of 
cases of cerebral tumor. It has so happened that only one case 
of cerebral tumor, strictly speaking, had choked disc. 

This was a case % I had in 1880, which, during life, had a 

- N. Y. Medical Journal, April 21st, 1883, p. 427. 

f Part of the discussion by Dr. Seguin of a paper entitled " Notes on Twelve 
Cases of Brain Tumor, chiefly with Reference to Diagnosis," by Chas. K. Mills, 
M.D. Read before the American Neurological Association, June 22d, 1882. 
Archives of Medicine, August, 1882. The discussion appeared in the trans- 
actions of the association for that year. From the Journal of Nervous and 
Menial Disease, July, 1882. 

\ Case reported in full, p. 495. 
39 



610 CHOKED DISC WITH CEREBRAL TUMOR, 

left hemiplegia and hemi-epilepsy, with chief symptoms in the 
arms and hand. 

An autopsy revealed a large sarcoma in the upper, middle part 
of the right ascending frontal gyrus. The presence of choked 
disc was verified by Dr. Amidon. 

All of my cases of basilar tumor have had choked discs. Also, 
a case of sarcoma within the medulla oblongata. In a case* of 
abscess located in the frontal lobe there was no paralysis and no 
aphasia, the symptoms being those of extreme pressure. The 
pulse was slow — 58, and lower at times. The optic nerves were 
somewhat congested, but there was no actual choking. 

A case of sarcoma of the upper part of the left, ascending 
frontal gyrus, near the longitudinal fissure, which presented, 
during life, hemiplegia and hemi-epilepsy with chief symptoms 
in the foot, had, up to day of death, no choked discs. 

A sarcoma of the left hemisphere, t developed in the para- 
central lobe, pressing inward, which produced its first symp- 
toms in the right foot — epileptiform attacks and paresis — later 
right hemi-epilepsy and hemiplegia, no aphasia, produced no 
choked disc. (Verified by Dr. Amidon). There was no headache 
in this case till a hemorrhage occurred from the exceedingly 
vascular growth. 

In a case of angio-sarcoma of the right, ascending frontal gyrus 
(other tumors present) with first and chief symptoms in the left 
hand and arm, there was no choked disc. (Verified by Dr. Bird- 
sail.) 

In a case of sarcoma from the pia, penetrating the right sphe- 
noidal lobe, the tumor being easily enucleated, there were 
marked pressure symptoms but no choked disc seventy-two 
hours before death. 

In a case where a node pressed upon the upper part of the 
ascending frontal and parietal gyri, near the longitudinal fis- 
sure, there was left hemiplegia, first symptom clonic convulsion 
in left foot and leg, and typical choked disc. 

I present these cases bearing upon the subject of choked disc 
not with the idea of lessening the importance of that symptom 
but with the intention of emphasizing the idea that we should 
not reject the diagnosis of cerebral tumor on account of not find- 
ing choked disc. 

"With the permission of the Association, I will make black- 
* Sec p. 452. f See p. 409. 



CHOKED DISC WITH CEREBRAL TUMOR. 611 

board illustrations of two of my cases of cerebral tumors. In 
one of the cases there was typical choked disc and excruciating 
pain; the lesions were in approximately similar regions, and 
nearly of the same size. Both tumors were globular. In both 
cases the first and principal symptoms were in the hand and arm. 
Yet in one case there was typical choked disc, in the other the 
optic nerves remained normal. 



YEKTEBEAL CANCEK AND PAKAPLEGIA.* 

Mrs. P., aged over forty years, was seen with Dr. Burlingham, 
at Plainfield, New Jersey, on Nov. 10, 1881. 

More than twenty years ago, while bathing, was struck in the 
left breast by a friend's elbow. Felt a good deal hurt at the 
time, and afterward said to this friend, " If I ever get cancer of 
the breast I'll blame you for it." No attention was paid to the 
small induration which remained. In the spring of 1879 this 




Longitudinal section of the bodies of the lumbar vertebrae, showing at a the elevation caused 
by the absorption of a vertebral body, the consequent approximation of cartilages and 
projection into the vertebral canal of the intervening tissue. 

lump grew and caused some pain. Dr. Burlingham, and Dr. 
Willard Parker of New York, advised its removal, which was 
done by Dr. Hart in the same year. The tumor was examined 



* Read before the American Neurological Association, June 22d, 1882. 
printed from the Journal of Nervous and Mental Diseases, July, 1882. 



Re- 



VERTEBRAL CANCER AND PARAPLEGIA. 613 

by some one for Dr. Parker, and was reported to be " myxo- 
sarcoma." 

In a few months a marked recurrence of the disease took place 
in the breast, with involvement of the axillary glands. A second 
operation was done by Dr. Hart in June, 1880 and everything 
removed ; it was a remarkably clean operation. 

Since that operation there has been only a small varying (?) 
tumor near the anterior axillary fold. Patient was married in 
the autumn of 1880. Soon became pregnant and seemed well. 

In December, 1880, driving home through the snow, was 
exposed to a cold wind, and both her feet wet. She fancied that 
the cold air "struck her left hip." In about two weeks began 
to complain of pains about the region of the left anterior superior 
spine of the ilium and below. Later had pain in right anterior 
femoral region. 

In January, 1881, had a first attack of spasm in the back. 
The head was thrown back, and the lower part of the back was 
tense, painful, and causing the body to be thrown backward. 
She continued to have more or less of this "drawing" feeling in 
the lower part of the back, often as low as the sacrum. Then 
she could not stoop or bend forward. 

Before her confinement early in February the pain appeared 
in both anterior femoral regions. This was a sudden attack of 
pain with " drawing " in the back ; the pain then increased, with 
spasm or cramps, throughout the hips, thighs, and feet. These 
attacks often lasted half an hour. Forceps were used in the 
confinement ; it was otherwise normal. 

In the spring she seemed better ; went about on foot, but had 
the same cramp pains developed early in the morning by turn- 
ing in bed. No numbness. In July was at the sea-shore quite 
wretched. In August Dr. Burlingham went to see her in con- 
sultation with Dr. Bisk. She then had more pain in the hips 
and back; lay in bed, afraid of any movement (of the left leg 
especially). Could not bring her heel to the ground. 

Toward the end of September there was gradual loss of power 
in the right leg, then complete palsy of the left leg, and lastly 
the right leg was completely palsied ; at the same time there 
were loss of feeling in the legs, and partial retention of urine. 

Six weeks ago (about October 1st) the paraplegia was com- 
plete, with anaesthesia, but no abnormal reflexes, and has so 
remained. Has lost color and weight progressively ; no fever (?). 



614 VERTEBRAL CANCER AND PARAPLEGIA. 

Complete extension (or rather the attempt to do this) causes 
severe tearing pains deep in the abdomen, above the umbilicus. 
Has a pseudo-cincture feeling above the umbilicus. Of late 
there have been some reflex movements in the legs. 

Examination. — The patient exhibits complete anaesthesia below 
a level 3 cm. above umbilicus in front, and as low as the pos- 
terior superior spine of the ilium behind. All voluntary power 
is lost below the epigastrium. Abdomen much distended ; im- 
pacted faeces can be felt in the ascending and descending colon. 
Pricking causes reflex movements. There are no symptoms 
above the umbilicus, except the axillary tumor (quiescent nodule). 

The spine presents two deformities : First, a well-marked 
kyphosis composed of three vertebrae in the lower dorsal region. 
Below this the spine is displaced anteriorly, and below ; in the 
lumbar region there is another kyphosis. 

The pains have ceased for several weeks. No alteration in 
nutrition ; some oedema of the paralyzed limbs. Bladder quite 
full (now micturates by reflex action). In August, Dr. Risk 
found a little albumen and some casts ; none since. Nurse re- 
ports thirst and flushing of cheeks in afternoon. Reflexes all 
raised. 

Diagnosis. — Pott's disease in lower mid-dorsal region, proba- 
bly from cancer of the vertebrae and of the dura mater ; compres- 
sion of the spinal cord. 

Clinically the symptoms are those of Cruveilhier's " paraplegie 
douleureuse." Advise no treatment. If pains return morphia to 
be given freely. 

On December 30th I recived the following letter from Dr. 
Burlingham : 

" Dear Doctor : The patient, Mrs. P., you saw with me died 
yesterday morning. There had been no very material change in 
her condition since you saw her, except a gradual and general 
loss of strength. The appetite was good, and digestion well 
performed. The distension of the abdomen was much less, and 
the ' drawing ' pains had almost ceased. Urine passed some- 
times without her knowledge, and about two weeks ago was very 
bloody for a couple of days. The evening temperature ranged 
from 37.8° C. to 40° C. ; morning temp, nearly normal. For the 
past month there has been a very considerable reflex action in 
the legs, the left one more violently ; and she complained of her 
feet aching. 



VERTEBRAL CANCER AND PARAPLEGIA. 615 

" Bed-sores formed over the trochanters and the sacrum. 
Forty-eight hours before death she first complained of stiffness 
about the jaws. Clonic spasms now followed, involving the 
facial and throat muscles, and causing a fear of choking to death. 
These continued till about half an hour before death. 

" A post-mortem examination was made about eight hours after 
death. 

" The spinal column only was examined. I send herewith the 
portion removed for your inspection. 

" We did not find the bodies of the vertebrae in the condition 
in which you regarded them at the time. 

" The mental condition of the patient remained clear until 
within fifteen minutes of death." 

Had not Dr. Burlingham taken the trouble to send me the 
vertebrae the case might have remained an anomalous and dis- 
couraging one for the student of spinal affections. The bones 
viewed externally after death seemed nearly normal. 

The portion of the vertebral column sent consisted of two seg- 
ments, one from lower dorsal and one from the lumbar region. 

In both these portions, several bodies contained round masses 
of grayish gelatinous cancer, some nearly 2.75 cm. in diameter, 
quite destroying the cancellous body. At two points, one in the 
dorsal region, there was absence of an entire body, with projec- 
tion of the anterior wall of the vertebral canal upon the spinal 
cord, causing compression of that organ ; this was at the 10th 
dorsal. The adjacent bodies had come together, causing the 
kyphosis observed during life. A similarly total destruction of 
a vertebral body had taken place in the third lumbar vertebra, 
causing some pressure upon the cauda equina. The smaller 
nodules were of varying size and age ; all, however, gelatinous 
and tending to the classic globular form. There was no trace of 
cancer in or about the cord. 

A microscopic examination of the spinal cord showed no dis- 
tinct secondary degeneration, but a well-marked, diffused mye- 
litis. This finding, with the fact that the projection of the 
remains of the 10th dorsal vertebra in the canal was small, makes 
it probable that the spinal cord suffered more from an irritative 
process than from simple compression. 



MYELITIS FOLLOWING ACUTE AKSEMCAL POISON- 
ING (BY PARES OE SCHWEINFUETH GEEEN).* 

The physician who, meeting with a case of arsenical paralysis, 
would seek for information on the subject in the accessible and 
contemporary treatises upon diseases of the nervous system, 
would be grievously disappointed. Such writers as Grasset, 
Eoss, Wilks, Bauduy, Hamilton, do not mention the affection at 
all ; the illustrious Eomberg and Erb merely give it a passing 
reference. Prof. Hammond (1881) in the last edition of his 
treatise, says nothing of paralysis following acute arsenical 
poisoning, and refers to paralysis and anaesthesia as results of 
slow poisoning. Apparently he has seen no cases of arsenical 
paralysis. Eosenthal (1875) devotes only a short paragraph to 
arsenical nervous symptoms ; refers to paralysis in the course of 
chronic poisoning. In a case which he saw there were paralysis, 
partial anaesthesia, and diminished electro-muscular contractility. 
Leyden (1875) in his classical work on diseases of the spinal 
cord,t gives a resume chiefly after Leroy D'Etiolles.t He does 
not appear to have had cases of his own, and considers the 
disease a neuritis. 

A little more extended research in older books, and in period- 
icals, brings to light numerous observations and some valuable 
experimental studies upon the subject. 

Indeed, arsenical paralysis seems to have been very early 
noticed, and to have attracted considerable attention until 
within the last twenty years. As early as the thirteenth century 
P. Abano§ refers to paralysis and contractures after arsenical 
poisoning. These symptoms are also mentioned by Forestus II 

* Read at the meeting of the Medical Section of the New York Academy of 
Medicine, October 17th, 1882. (The original cases alone had already been read 
before the American Neurological Association, at its Eighth Annual Meeting, 
June 21st, 1882.) Reprinted from the Journal of Mental and Nervous Disease, 
vol. ix., No. 4, October, 1882. 

f Klinik der Ruckenmarks-Krankheiten, Bd. ii., p. 296. 

% Gazette Hebdomadaire, Tome 4, 1857, pp. 141-144. 

§ De venenis eorumque remediis, cited by Imbert-Gourbeyre, I. c. 

1 Cited by Imbert-Gourbeyre, I. c. 



ARSENICAL PARALYSIS. 617 

(about 1560-70) ; and Zacchias * (1630) mentions paralysis, 
spasms, contractures, and anaesthesia as following poisoning. 
From that time arsenical paralysis is frequently mentioned by 
medical writers. Hahnemann,t in one of his earlier works, 
(1786;, relates several cases. 

In 1812, Sir Benjamin Brodie, in an interesting communica- 
tion to the London Boyal Society, entitled " Observations and 
experiments on the actions of poisons on the animal system," 
devotes a section to the effects of arsenic, and relates how in 
several of his animals (rabbits and dogs) the hinder extremities 
became paralyzed. He considered the brain to be affected in 
these cases. 

The following interesting case was published, in 1809, by Dr. 
G. Thilenius4 

A young lady having observed a hard lump in her left breast, neglected it 
until the ensuing spring, when it became very painful. A miserably ignorant 
barber, who was consulted, applied a preparation of arsenic. This was 
followed by ulceration and increased pain, and, according to the father's 
statement, three days later her arms and legs became insensible, and so much 
paralyzed that she could neither walk nor feed herself. The limbs were also 
cold. In the course of two months the arms recovered, and the legs improved 
steadily. Electricity was used ; the tumor removed by the knife. "At various 
times there occurred prickling and jerking in the legs. Anaesthesia and 
atrophy not mentioned. 

In about a year after the attack the patient was able to walk without a cane; 
her limbs were warm, and the wound in the breast well healed. 

In 1793 (three years after the attack) patient was perfectly well, married, 
and had a child.— Obs. No. 80 of Leroy D'Etiolles.) 

Orfila,§ the great French chemist and toxicologist, in experi- 
ments upon dogs, made prior to 1840, noticed paralysis of the 
hinder extremities in dogs which survived arsenical poisoning 
(also in fatal experiments). 

Prof. Christison, || of Edinburgh, in his classical wOrk on 
poisons, treats of symptoms of arsenical poisoning in a mas- 
terly way. He makes three categories of cases of arsenical poi- 
soning. In a first class of cases, in which, with symptoms of 
violent inflammation of the gastro-intestinal tract, death results 

* Quaestiones medieo-legales, Romae, 1621-50, cited by Imbert-Gourbeyre. 

f LFeber das Arsenik-Vergiftung, Leipzig, 1786, cited by Imbert-Gourbeyre. 

% Medic. -chirurgische Bemerkungen, Frankfurt, 1809, in Leroy D'Etiolles, p. 63. 

§ Traite de Toxicologic, Paris, 1852. 

J A Treatise on Poisons, Phila., 1845, p. 244, et seq. 



618 ARSENICAL PARALYSIS. 

in from twenty-four hours to three days ; nervous symptoms not 
present. In a second class of cases, with little evidence of in- 
flammation, extreme prostration and syncope are the chief symp- 
toms, death occurring within six hours ; no paralysis observed. 
Convulsions may close the scene. In the third category, that of 
subacute cases, there is moderate gastro-intestinal inflammation ; 
symptoms are same as in other classes, but milder. In the later 
stage these cases are apt to show marked nervous symptoms : 
coma, epileptoid attacks, mania, tetanus, hysterical seizures, 
partial paralysis resembling lead paralysis in affecting the ex- 
tremities ; contractures may exist. In speaking of symptoms 
connected with irritation of the primce vice, Christison makes 
this shrewd remark, which applies critically to many of the 
older cases of arsenical paralysis : " Cramps in the legs and 
arms (occur in arsenical poisoning), a possible concomitant of 
every kind of diarrhoea." 

The father of modern clinical medicine, Graves * (1842), after 
speaking of paraplegia from inflammation of the bowels, refers 
to Orfila's experiments in which all (?) the dogs which survived 
arsenical poisoning were paralyzed in their hinder limbs, and 
states that in his opinion in cases of arsenical as well as of lead 
poisoning, the poison acts directly on the central nervous sys- 
tem (spinal cord), and that the palsy is not due to the intestinal 
irritation. 

Huss,t of Stockholm, in his work on alcoholism (1852), men- 
tions several cases of arsenical poisoning with severe nervous 
symptoms. He gives one which is instructive as regards its 
etiology. 

For the cure of intermittent fever, a large teaspoonful of Fowler's solution 
was given at one dose (equivalent to .035 of arsenious acid). After the usual 
symptoms of acute intoxication, there gradually ensued an almost complete 
paralysis, of the extremities, with anaesthesia of the hands and feet, severe 
pains and cramps in the lumbar region and lower extremities. 

In 1857 we meet with quite an important contribution to this 
subject. Leroy D'fitiolles, X iu his work on paralysis of the 
lower limbs, devotes a chapter to arsenical paralysis, and relates 

* Clinical Lectures, Gerhard's edition, Phila., 1842, p. 94. 

f Cited by Tmbert-Gourbeyre. 

X Des paralysies des membres inferieurs, deuxieme partie, p. 28, et seq., Paris, 

1857. 



ARSENICAL PARALYSIS. 619 

the following three cases (in addition to the case of Thilenius 
already quoted). 

Obs. 79. — Poisoning from external application of arsenious acid ; general 
paralysis ; recovery of upper extremities first. 

Male patient . . . aged. Dr. Trochon, of the hospital at Pornic, amputated 
his leg for cancer. In the cicatrix cancerous buds appeared. Arsenical paste, 
made one hundred times too strong by druggist's error, was applied, and 
very soon symptoms of acute intoxication appeared ; life saved with difficulty. 
At the end of ten days patient convalescent, but with well-marked paraplegia 
and paresis of the arms. 

Seen five months later by Leroy : Arms weak and not adroit; tendency to 
drop wrist. Marked paralysis in remaining lower extremity, with emaciation, 
but not positive atrophy of muscles ; contracture in semi-flexion ; foot hyper- 
extended (pes equinus); toes flexed. Sensibility to touch and pain much im- 
paired on limbs. Electrical tests not used. 

Gradual improvement of paralysis in spite of progressive cancerous infection. 

This case bears a certain resemblance 'to my own cases. Al- 
though it is stated that the muscles were not atrophied as in 
lead paralysis, yet from the contractures and the degree of emaci- 
ation present, it seems to me highly probable that there was 
atrophy, widely distributed, as in mild cases of poliomyelitis. 
It is a pity that electricity was not used, although at the time 
when this observation was recorded, 1855, only the bare fact of 
diminution or loss of faradic contractility could have been 
determined. 

The contracture in flexion with pes equinus is strikingly like 
what existed in my own Case 3. 

Obs. 81. — Poisoning by the ingestion of arsenious acid; paresis of arms; 
paraplegia lasting fourteen months. 

A female patient aged thirty-seven years, was admitted to the service of Dr. 
Bouvier, Hospital Beaujon, January 22, 1850, suffering from severe toxic 
symptoms produced by eating cakes charged with arsenous acid. 

As soon as the urgent symptoms had subsided (time not noted), it was dis- 
covered that the patient was paralyzed in her lower limbs, and that they were 
the seat of painful jerking (reflex movements ?). Her arms were weak. On 
18th February, on leaving the hospital, she was unable to stand, and said that 
she could not feel the floor under her feet. In September of the same year 
she was readmitted with pleurisy; and it was noted that while her arms had 
recovered, her legs were just as weak, and as insensible to touch. At no time 
was there interference with the functions of the rectum or bladder. Later 
some improvement took place, but the patient finally died of exhaustion 
caused by a profuse diarrhoea. No autopsy. 

Obs. 82.— Case of Aran in Union Medicale, July 6, 1852. On June 9, M. 



620 ARSENICAL PARALYSIS. 

Aran presented to the Societ6 MMicale des Hopitaux, one of two young men 
who had, two months previously, been poisoned by arseniate of sodium. The 
victims had swallowed this salt, supposing it to be tartrate of sodium. One 
died in twenty-four hours ; and a lady to whom they had given some of the 
poison, is not yet perfectly well. 

In the surviving male patient interesting nervous symptoms have appeared. 
In about fifteen days after the ingestion of the drug, symptoms of paralysis 
appeared in the lower limbs, more marked in the right leg. The upper ex- 
tremities have also been weak. The paralysis has remained very much in 
statu quo. The paralyzed parts are somewhat anaesthetic. The lower limbs 
are the seat of tingling below the knees ; and the upper extremities in the 
finger-tips. At one time the paretic extremities showed diminished calorifica- 
tion. General health good. 

M. Duchenne examined the young man and found slight diminution of elec- 
trical irritability, and the skin showed diminished sensibility to the current. 

Later, on 8th September, M. Aran reported to the Society that the patient 
had recovered, apparently in consequence of forty-six baths and forty-six 
douches at Bagneres de Luchon (hot sulphur springs). Improvement showed 
itself distinctly after the thirty-sixth bath. 

Leroy makes these general statements: In lead paralysis the 
forearms are usually affected (sometimes only one) ; arsenical 
paralysis tends to involve all the limbs ; the lower limbs are 
more affected ; often there is well marked paraplegia ; the action 
of the bladder remains normal. Sensibility is usually much 
impaired (nearly as much as motility). He refers to wasting of 
muscles, but states that it contrasts with the positive atrophy 
of lead paralysis. Electro-muscular contractility persists, but 
is diminished. Treatment is efficacious, and the duration of the 
paralysis is usually less than one year. 

Shortly after the appearance of Leroy D'Etiolles' work, a 
learned French physician, Imbert-Gourbeyre,'"" professor at the 
medical school of Clermont-Ferrand, published a series of arti- 
cles in the Gazette Medicate (.1858), in which he gave an elaborate 
account of our previous knowledge of arsenical paralysis. I am 
indebted to this essay for bibliographical data. The articles 
contain nothing original. In 1863, Smoler f published a case of 
paralysis after acute arsenical paralysis, which is referred to by 
Eosenthal (1875). 

Jaccoudt (1864) devotes several paragraphs to arsenical 

* Etudes sur la paralysie arsenicale. Gazette Medicate, 1858, pp. 5, 19, 59, 94. 
f Lahmung nach Arsenikvergiftung. (Esterreich.Zeitschr.furpract. Heillcunde, 
1863. 

X Les paraplegies et l'ataxie du mouvement, Paris, 1864, p. 323, et seq. 



ARSENICAL PARALYSIS. 621 

paralysis (paraplegia), and expresses his belief that the palsy 
is caused by the direct action of the metal or its compounds 
upon the tissue of the spinal cord. He does not, however, 
appear to have seen a case. 

In 1881, Seeligmuller* placed on record four cases ; two 
aftor acute poisoning, and two other chronic intoxication. In 
his acute cases he noted paralysis, numbness, and anaesthesia 
(in toes), contractures, wasting of the extensors especially. 
The paretic and wasted muscles showed fibrillary contractions ; 
the nails were gradually lost, Electro-muscular contractility 
was diminished or even lost. 

He gives the following points for differential diagnosis from 
lead palsy : the acute origin of the paralysis, disorder of sensa- 
tion as well as of motion, rapid muscular wasting, absence of 
blue line on the gums, and of cachexia. 

In the same year appeared the essay of Popow,t of St. 
Petersburg, upon the pathological anatomy of arsenical paraly- 
sis as produced artificially in animals. Popow carried on his 
experiments under the guidance of Prof. Mierzejewski ; giving 
arsenious acid to dogs in doses ranging from .003 to .12 at a 
dose, producing acute and chronic intoxication. 

In cases where death ensued in four or five hours after inges- 
tion of the poison, the spinal cord showed both macroscopic and 
microscopic lesions. The gray matter ajDpeared swollen, in- 
tensely red, more especially in its two enlargements. Micros- 
copic examination revealed enlargement and congestion of the 
small l)lood-vessels, and accumulations of lymph corpuscles in 
the lymph-spaces. 

There was also abundant extravasation of blood-corpuscles 
and plasma around the vessels, especially in the central por- 
tions of the gray matter. The walls of the blood-vessels were in 
a state of fatty degeneration. 

The ganglion cells exhibited three degrees of change. A first 
degree of alteration showed cells well stained by carmine, and 
containing vacuoles of variable sizes, some of which could be 
traced into the cell-processes. A second form of cells had no 
processes, were feebly colored by carmine and exhibited a 
punctate granular infiltration. Lastly, here and there were cells 

* Ueber Arseniklahmung. Deutsche med. Wochenschrift, 1881, No. 14, et seq. 
f Ueber die Vevanderungen im Ruckenmarke nach Vergiftung mit Arcen und 
Blei. St. Petersburger med. Wochenschrift, 1881, No. 33. 



622 ARSENICAL PARALYSIS. 

in a third state of change, consisting only of a nucleus sur- 
rounded by dark brick-red pigment. The white substance only 
showed pigment masses here and there, more especially about 
the blood-vessels. 

In cases of acute intoxication in which a fatal result ensued 
in the course of three, five, or six days, the distinction between 
the white and gray substances of the spinal cord was less de- 
fined. The vascular injection and the exudation of plasma were 
less marked, but on the other hand the changes in the ganglion 
cells were more distinct, the vacuoles larger, and the granular 
state more pronounced. There were more cells, or properly 
remains of cells, of the third category above described. The 
white substance was normal, except some enlargement of blood- 
vessels, and considerable accumulations of pigment. 

In the chronic cases, those in which death occurred in the 
course of three months (one animal had paresis of the hind legs 
not long before death), the spinal cord appeared less firm, and 
the microscopic appearances differed noticeably from those 
observed in the acute cases. 

The walls of the blood-vessels were much thickened, and 
showed a distinct fibrillary structure, with diminution of the 
calibre of the vessels, and exudation of blood in the perivascular 
spaces. In the meshes of the perivascular spaces were extensive 
hyaloid masses. The number of ganglion cells was much 
diminished; those remaining showed large vacuoles, and be- 
longed to the first group described. In these cases the white 
substance was much more affected, especially in the postero- 
lateral columns. The cylinder-axes exhibited points of swelling 
here and there ; they were granular ; in many preparations they 
were merely represented by groups of fine granulations. The 
septa of the white substance likewise exhibited a granular 
change ; and the periphery of the white and gray substances was 
thickly strewn with small masses of black pigment. 

The spinal nerves, carefully examined at their origin, and at 
various points of their course and distribution, presented no 
pathological alterations. 

From these post mortem observations Dr. Popow concludes 
that : 

1. Arsenic, even in a few hours after its ingestion, may cause 
distinct lesions of the spinal cord, of the type known as acute 
central myelitis, or acute poliomyelitis. 



ARSENICAL PARALYSIS. 623 

2. In the more chronic cases the pathological changes are 
found in the white as well as in the gray substance, constituting 
a diffused myelitis. 

3. The peripheral nerves remain normal, even three months 
after intoxication. 

4 The paralysis of arsenical poisoning is of central origin. 

It might be added that in three guinea-pigs poisoned by lead, 
and dying on the sixth, seventh, and tenth days, similar lesions 
were found, i. e., evidences of more or less diffused myelitis, and 
no lesions of peripheral nerves. 

This essay, issued under the supervision of so distinguished 
a neurologist and microscopist as Prof. Mierzejewski, is in many 
respects the most important contribution to the subject. Con- 
necting its conclusions with inductions which can be legitimately 
drawn from the cases of Leroy, Seeligmuller, Smoler, and Rosen- 
thal, and my own, we are able, I think, to form a definite con- 
ception of the true nature and relations of arsenical paralysis. 

In last year's Philadelphia Medical Times Prof. J. M. Da Costa * 
relates a case of subacute myelitis which occurred in a man who 
had been taking " small pinches " of arsenic (arsenious acid ?) 
for three months. The general features of this case and the 
paralytic phenomena are so unlike what has been observed in 
the other cases referred to in this paper, that I entertain a 
doubt as to its having been an " arsenical paralysis." The rapid 
improvement under very large doses of iodide of potassium, and 
the history of a venereal sore one year before admission, would 
seem to furnish a better clue to the nature of the myelitis. 

The cases which have fallen under my own observation are 
three in number. The subjects were all would-be suicides with 
Paris green,t and they presented remarkably similar symptoms. 
In many respects the cases resembled those already related. 



* Clinical Lecture on Arsenical Paralysis, PJiila. Med. Times, Vol. II., p. 385, 
614. 

f Paris or Schweinfurth green is a compound substance which is best designated 
as aceto-arsenite of copper. 

In looking up this point I was astonished to find that such a popular and so con- 
stantly used a term as Paris green, was not to be found in the indexes of any of 
Dur dispensatories, treatises on materia medica, and, stranger still, not in works on 
toxicology. 

Prof. Chas. F. Chandler, in reply to a note, very kindly gave me all necessary 
chemical information on the subject. 



624: ARSENICAL PARALYSIS. 

Case I. — Samuel L., hostler, seen March 21, 1879, in consultation with 
Dr. M. Burke. 

At the end of January, while in good health, swallowed a large quantity of 
pulverized Paris green. Had much difficulty in swallowing it, and very soon 
was led to a drug store, where emetics were given ; and later he was taken to 
Bellevue Hospital, where the stomach-pum^) was thoroughly used. Vomiting, 
gastric pain and irritation, extreme prostration, lasted four or five days. 

Soon after he began to go about his room, he noticed numbness in his 
fingers and hands, followed in two or three days by similar sensations in his 
feet. Paresis appeared about the same time in all the extremities, and had 
steadily progressed to extreme paralysis below the knees, with wasting of the 
muscles there. Has had much burning, gnawing pain in soles and insteps ; a 
little in the hands. Ten days ago became unable to stand. No cerebral 
symptoms, or palsy of bladder, or jerking of legs. 

Examination.— Hands and forearms only weak ; no positive paralysis or 
atrophy ; no anaesthesia. 

Legs completely paralyzed below the knees ; cannot move feet or toes. 
Thigh muscles are weak. Marked atrophy of calves and .of anterior tibial 
muscles. No anaesthesia of soles, unless it be a slight tactile dullness . 

Test with faradic current ; no reaction in right leg, nerves, or muscles. In 
left leg no reaction in anterior tibial muscles or nerves, but a feeble contrac- 
tion can be produced in the calf. 

Patient is at times hysterical. 

At fifteen had a chancre, not followed by secondary symptoms. 

I have no further notes of the case ; but some sort of galvanic treatment 
was carried out . A few months afterward I learned that the patient was well, 
and some time in the winter of 1880-81 he came to my office and exhibited a 
vigorous pair of legs. He had completely recovered and was at work again as 
a hostler at Jerome Park. 

Case II. — Mary N., aged sixteen years, was admitted to the New York 
Hospital on December 11, 1878, in the service of Dr. Woolsey Johnson. To 
Dr. R. W. Amidon, then house physician of the hospital, I am indebted for 
notes of the case and for the opportunity of studying the case in its later 
stages. Dr. Johnson has kindly given me permission to use the case. 

The patient was a strong, rosy-cheeked girl of German parentage. She 
had never suffered from rheumatism or malaria. Thirteen days before ad- 
mission she swallowed five cents' worth of Paris green. In five minutes she 
vomited, and after an emetic had been given she vomited again, rejecting 
all (?) that had been swallowed. Probably had some gastro-enteritis, as she 
vomited and purged for two or three days. 

It is reported (by patient and her friends) that on the first night she had 
fever. Second day, no fever or pain. Third day, at three p.m., had fever 
for one hour and a half ; burning pain in toes ; hands felt stiff. On the fifth 
day, at nine a.m., fever returned, with slight headache, but no chill. The 
burning pain extended up to the knees. One week after taking the poison 
her legs became stiff, and she lost power in her arms ; had "cramps " in her 
hands. These symptoms continued, but the headache ceased, tried to walk, 
but found that she was partially paralyzed in her legs ; needed help to walk, 



ARSENICAL PARALYSIS. 625 

and suffered pain in her knees (in the attempt). Three days later (tenth day) 
loss of power increased ; had cramps in hands ; had tightening sensations in 
hands and feet, and they began to peel and showed a mottled red and white 
appearance. Bowels and bladder normal. 

Has not been unwell for twelve weeks ; previously regular. 

Condition on admission, thirteen days after taking poison : Patient com- 
plains only of headache, and of inability to walk, because "cords of knees 
are stiff.'' Appetite, bowels, bladder, and eyes normal. 

Hands are cold and moist. The extensor muscles of both hands are weak, 
those of right hand weaker. Some twitching of long flexors and of interossei. 

The skin is lax. The small muscles of the region of the right little finger 
are completely paralyzed and wasted. The right thenar eminence is smaller 
than it should be. The hypothenar group on the left side is in the same 
condition. Grasp very weak. On dynamometer each hand shows about 20° 
(on outer circle). There is hyperidrosis. No anaesthesia is present, but she 
complains of a burning when pricked with a pin. 

The legs are semi-flexed, showing mostly palsy of the extensors of both feet. 
The left foot is more inverted than the right. Legs and thighs smaller and 
colder than normal. Toes are red ; the circulation is sluggish. The muscles 
of the legs are not flabby, but the anterior tibial regions are flattened. Ham- 
strings rigid on both sides. 

Circumference of right thigh, 30.5 ; right leg, 23.5. 
" left " 30.5 ; left " 24.5. 

There is complete paralysis of the anterior tibial muscles. The peroneal 
and posterior tibial groups are somewhat atrophied ami paretic. Great toes 
are motionless. Flexion of thighs is moderately good ; extension complete. 
No increased reflex actions. Is rather hypera?sthetic (in legs). 

Dec. 14th. A tendency to retention of urine is noted (but is not again re- 
ferred to). Examination with the faradic current showed good contractions 
in left thenar and hypothenar eminences, but none in the right. In the right 
leg there is slight reaction in the anterior tibial muscles ; none in the peronei. 

Dec. 26th. It is noted that there is no faradic reaction in the anterior tibials 
and peronei. Sensibility is good. Hamstrings less rigid. Patient has plaster 
apparatus for legs, and the application of the faradic current. 

Jan. 11, 1879. Walks with some support, and has done so for a week. Left 
leg nearly straight. 

Jan. 15th. Circumference of right thigh, 34.0 ; right leg, 24. 

left " 34.5 ; left " 26. 

Toes always cold and moist ; tender to slight pressure. Less contraction 
of hamstrings. No reflex actions in legs. Interossei of hands do not im- 
prove, and remain as flaccid, atrophied, and weak as on admission (faradism 
not used on upper extremities). 

Jan* 24th. Galvanism tried for first time; ten cells cause contraction of 
tibialis and peronei ; eight cells (Stohrer battery) cause contraction of quadri- 
ceps, sartorius, and muscles of calf. Some atrophy of extensors of the right 
forearm and hand ; good reactions (current not stated) in ulnar distribution, 
40 



626 ARSENICAL PARALYSIS. 

but not, in wasted extensors. On the left side good reaction in forearm and 
hand, except abductor pollicis, to both galvanism and faradism. 

Jan. 27th. Menses appeared with great pain. 

Feb. 4th. Electrical applications omitted because of malaise. Patient doing 
nicely ; muscles react with small amounts of electricity. 

Feb. 9th. Some trophic changes in feet ; nail of big toe coming off. The 
skin is rough, and there is vaso-motor disturbance. Reactions improving 
(in legs). 

March 10th. Walks quite well. Some remaining weakness of anterior tibial 
muscles. 

Discharged improved. 

This patient at once began to be treated as an out-patient at the Manhattan 
Hospital, and after several weeks of treatment by galvanism mostly was com- 
pletely cured. 

The notes taken at this time have been misplaced, but our recollection is 
clear that her upper extremities were about well, though perspiring, and that 
the lower limbs exhibited paresis, a sluggish circulation, and a peculiar sen- 
sitiveness and tenderness. She was able to walk alone, but lame. Her gen- 
eral health was quite good. 

It seems certain that this was a case of subacute poliomye- 
litis chiefly. The inflammatory action must have extended to 
deeper parts of the gray matter, as shown by continued hyper- 
algesia and by the contractures. 

Case III. — Ellen R., aged twenty-six years, admitted to Manhattan Hospital 
May 10, 1881. In September, 1880, took a large dose of Paris green. Was 
exceedingly ill ; vomiting and diarrhoea. In a week nearly complete paralysis 
developed. Legs completely paralyzed ; forearms the same. 

A gradual recovery began in the course of a few weeks (no treatment). 

Three weeks before admission to the hospital, Dr. J. B. Emerson, who 
visited her in the country, found her fingers and the soles of her feet nearly 
insensible to pricking. I examined the patient May 9, 1881, and the follow- 
ing notes were taken. Can walk with a little aid, impeded by moderate con- 
tracture of right knee, and tenderness of feet. No voluntary power (motion) 
below ankles. Complete anaesthesia to contact on soles of feet and on finger- 
tips. Feels cold and heat, however, and pricking quite well. The upper 
extremities simply present a slight paresis with moderate wasting of the hand 
muscles, some interossei quite wasted, and some large fibrillary movements in 
the same. No cutaneous trophic changes. Thighs moderately wasted, with 
some contracture of right hamstrings. No patellar tendon reflex. Calves 
and anterior tibial muscles are much wasted ; legs and feet bluish and cold ; 
slight tactile anaesthesia of feet. 

Patient is thin and in poor health : has been using an unknown quantity of 
morphia. 

She was ordered a mixture containing diminishing amounts of morphia ; 
and Dr. Adam, assistant physician of the hospital, applied galvanism and 
faradism very faithfully to her for weeks. He also gave her passive move- 



ARSENICAL PARALYSIS. 627 

ments and massage. The improvement was steady, and in a few weeks 
patient left the hospital almost perfectly cured as regards paralysis, and in good 
general health. She was forty-eight days in the hospital. The day after 
admission Dr. Adam made a thorough testing of the affected muscles with 
the galvanic and faradic currents, which may be summed up by saying that 
most of the paralyzed parts exhibited the degeneration reactions, viz.: 
1, diminished or wholly lost faradic reaction in muscles and nerves; 2, sluggish 
contractions to galvanism, with ancc=cacc in many muscles, and ancc ~> cacc 
in some. For example, in the muscles of the leg below knees a very strong 
faradic current caused no reaction. In the right gastrocnemius ancc > cacc. 
In other muscles cacc=ancc. In some interossei of hands ancc>cacc. 

This patient is again under my care at the Manhattan Eye and Ear Hospital 
(October, 1882), for the cure of the ouly remaining weakness, viz. : paralysis 
of both anterior tibial muscles causing pes valgus. This is the only muscle 
which does not respond to the will, but all the muscles of the leg show a 
most astonishing quantitative reduction in electrical reactions; no reaction 
in muscles or nerves to full strength of faradic secondary current, and few 
small reactions in nerves and muscles to fifty good Leclanche elements. 
Reactions obtained are of normal quality. 

In this case, besides the contracture of the hamstrings, as in 
Case II., we have distinct though slight anaesthesia to indicate a 
certain extension backward of the lesion, in the spinal gray 
matter. 

To sum up, these three cases presented evidences of slight 
subacute, diffused myelitis, more distributed in the anterior 
cornua. In Case I. the symptoms were more purely those of 
poliomyelitis. 

In all cases the symptoms of myelitis followed within a week 
after the ingestion of the poison. 

If we compare the symptoms present in the various human 
cases related and quoted, and the pathological arjpearances found 
by Popow in his animals, it is, it seems to me, legitimate to 
reach the following conclusions : 

1. Arsenical paralysis is the expression of a myelitis. 

2. This myelitis approximates the type known as poliomyelitis 
in so far as the symptoms are chiefly motor ; that the paralyzed 
muscles undergo some atrophy, and exhibit the degeneration 
reactions to electrical currents ; that the bladder is never 
palsied ; and that in animals the ganglion cells of the anterior 
horn are extensively diseased. 

3. There is Ti^airy-rirora-iiiaTr^p^ by 
Popow's post-mortem findings, and by the presence in living 



628 ARSENICAL PARALYSIS. 

human subjects of pains in the nerves and muscles of the 
affected limbs, and by the occurrence of actual anaesthesia, 

4. Consequently it might be better to speak of arsenical 
paralysis as due to diffused central myelitis with special involve- 
ment of the anterior gray matter. 

5. Whether this myelitis is strictly arsenical, i.e., caused by 
the direct effect of the arsenic on the tissue of the spinal cord, 
or whether it is produced (as are many forms of myelitis) by the 
irritation of peripheral nerves (cutaneous, intestinal and gastric 
nerve-endings), is a question which cannot at present be defi- 
nitely solved, but which presents an interesting field for future 
research and speculation. 



ON A PECULIAK CUTANEOUS LESION (ULCUS ELE- 
VATUM) OCCURRING DURING THE USE OE BRO- 
MIDE OF POTASSIUM.* 

In the last few years, more especially since the publication of 
Trousseau's lecture entitled "Exanthemes sudoraux" t much atten- 
tion has been paid to toxic or medicamentous eruptions. 

Among these, the cutaneous lesions produced by the various 
bromides, when taken internally, have been particularly well 
studied, and quite a variety of eruptions have been observed and 
recorded by dermatologists and neurologists. 

In the last edition of Prof. Duhring's excellent work J we find 
a section devoted to this subject, and the following bromic erup- 
tions are described under the head of dermatitis medicamentosa. 

1. Acne-form pustules. 

2. Brownish discoloration of the skin. 

3. Simple papular eruption. 

4. Confluent or molluscoid acne. 

5. Maculo-papules. 

6. Carbuncular acne. 

7. Bulla*. 

8. Rupia. 

Ulcers are not named in this list, and I do not know that they 
have ever been described, unless it be in the shape of isolated, 
ulcerated, carbuncular acne.* 

It has been my fortune to observe this year two cases of large, 
elevated ulcers upon the legs, occurring in epileptic patients 
using the bromide treatment, and I desire to place on record 
this new form of cutaneous lesion, probably medicamentous in 
origin. 

* From the Archives of Medicine, Oct., 1882. 

f Cliniquc medicale de VHotel-Dieu, 2me ed., 1865, i, p. 199. 

\ " Practical Treatise on Diseases of the Skin," 3d ed., Phila., 1882, p. 348. 

* Dr. A. Voisin, in his monograph, "De l'Emploi de Bromure de Potassium 
dans les maladies Nerveuses," Paris, 1875, mentions a very similar lesion, which 
undoubtedly Dr. Seguin had overlooked. — [R. W. A.] 



630 BROMIC ULCERATION. 

Case I. — Miss C, aged 25 years, epileptic since her fourteenth year. The 
disease has been fairly well controlled by moderate doses of various bromides, 
under the supervision, in the last few years, of her physician, Dr. P. C. 
Barker, of Morristown, 1ST. J. Very little facial acne has appeared, and at no 
time has severe bromism been apparent. Some ten years ago, while the 
patient was in Germany with her family, there appeared some "boil-like'' 
sores upon the lower part of each leg, which soon coalesced into ulcers, one 
on each leg, presenting very much the same appearance as those of later 
development about to be described. On the left leg there was an "ulcer," 
also below the head of the fibula. In a few months these ulcers healed. So 
far as the mother of Miss C. knows, there was no increase in the amount of 
bromides, or change of bromide, prior to the appearance of the. eruption, nor 
does she remember any special treatment, other than the .application of some 
herbs to the sores, which determined their healing. The patient, continuing 
the bromide (various formulae) treatment steadily, had no further serious 
eruption or ulceration, indeed "no special bromic symptoms, until about fifteen 
months ago, when large, purplish papules, like "boils," appeared upon the 
outer side of each leg, about four inches above the external malleolus. These 
discharged, leaving ulcerated spots which coalesced, forming an ulcer which 
increased steadily in size until the early spring of this year, when I saw the 
patient. This account of the early appearances and development of the sores 
is derived from the patient's mother, whose qualifications as an observer are 
fair. Still, the lack of professional study of the early stages of the lesion is a 
hiatus much to be regretted. It is doubtful if the ulcer was ever a common 
excavated one; Mrs. C. thinks that for months prior to my examination its 
surface was distinctly raised above the level of the healthy skin. 

"When I saw Miss C, in March of this year, there was a large ulcer on each 
leg, almost encircling it, leaving a bridge of healthy skin over the anterior 
surface of the tibia. The rest of the leg, at a level about four inches above 
the malleoli, was covered by an irregular ulcerated patch, raised from 2 
to 4 mm. above the skin. Its area was irregular, somewhat pear-shaped, with 
its largest development posteriorly. Its greatest width, vertically measured, 
was perhaps 8 cent. The surface of this "ulcer" was different from any 
thing I had ever seen. As stated above it was raised quite uniformly above 
the healthy skin ; its edges were abrupt, almost vertical, and showed no signs 
of cicatricial action. The elevated floor of the ulcer was firm, grayish-red in 
color, with here and there an adherent crust; it secreted a fetid, sanious, 
puriform liquid, and bled upon being touched with moderate violence. It 
did not look like ordinary granulation tissue ; it was much firmer, composed 
of larger masses, and, in fact, at several points it presented a slightly villous 
or rather papillomatous appearance. There was no burrowing of pus under the 
ulcer, and the rest of the leg was normal — perfectly free from "boils" or 
papules. This description, insufficient as I feel it to be, applies to both legs; 
the ulcers upon them were almost precisely alike ; the lesion was a symmetrical 
one. (On the left leg, just below the head of the fibula, was an irregularly- 
shaped, smooth, white and coppery cicatrix of the ulcer which appeared ten 
years ago, and healed in a few months.) The patient's face and neck pre- 
sented hardly a trace of bromic acne, and I was told that her body was free 



BR0M1G ULCERATION. 631 

from ulcers or other eruptions ; she showed none of the other symptoms of 
bromism, and her epileptic attacks were still recurring in a mild form occa- 
sionally. 

I was so mucli impressed with the firmness and elevation of these patches 
that I could not avoid a suspicion of epithelioma, in spite of the symmetry of 
the lesion which indicated its toxic or systemic origin. Prof. Henry B. Sands, 
to whom I then sent Miss C, decided that there was nothing malignant about 
the ulcers, and he looked upon them as eruptions connected with the patient's 
condition or with her medicines, and he sent her to Prof. William H. Draper, 
who also looked upon it as medicamentous eruption. Dr. Draper has recently 
written me as follows concerning the case : 

". . . I remember Miss C.'s case perfectly, even though I have no notes 
of it. . . . [ examined some scrapings from the ulcer and found only 
granulation cells. I think it was unquestionably a bromic acne. The lesion 
begins, I believe in the follicular structures, it is said in the sweat follicles, 
but I suspect in the sebaceous ones as well. . . .." 

Acting upon Dr. Draper's suggestions, Dr. Barker applied pyroligneous 
acid to the ulcers and they at once began healing. I saw the patient a fort- 
night ago and found the ulcers almost entirely healed, with copperish smooth 
cicatrices such as we see after common ulcers of the legs. 

•It is interesting to note that the bromide treatment was continued un- 
changed. 

Case IT. — Annie L., aged twelve years, was brought to me at the Manhattan 
Eye and Ear Hospital, on February 24, 1882, to be treated for peculiar attacks 
which I considered epileptic, and of a form intermediate between petit-mal 
and psychical epilepsy. In many seizures there were hallucinations of vision. 
The first attacks, which appeared about eighteen months ago, after a fever, 
were distinctly spasmodic. In the last few months more attacks of both 
sorts; right internal strabismus has appeared. Much complaint of headache, 
principally over the right eye ; grasp of right hand less strong than that of 
left. Further details concerning the neurosis are unnecessary for my present 
purpose. 

The child's health seemed good; she was fairly well-colored, and her skin 
was everywhere normal. 

She was put upon our regular bromide treatment, taking from three to four 
grammes a day at various times. The indications of coarse cerebral disease 
were so strong that I also gave her .75 gramme of iodide of potassium 
three times a day, and applied a few blisters behind the ears. 

The epileptic attacks were at once controlled, and the child seemed to bear 
the medicines well. Owing to some annoyance at having to wait very long 
one day, the mother ceased bringing the child to the hospital; this was some 
time in March, and there was then no bromism or eruption. 

Rather accidentally, Annie again came under my care in June, by being 
brought to my clinic at the College of Physicians and Surgeons. I at once 
recognized her, and upon inquiry found that she had had private treatment 
since leaving the hospital, and had taken bromide of potassium only (no 
iodide). The attacks had been few and slight, more of the psychic order: 
fear of falling down stairs, seeing animals, weeping, calling out to mother, 



632 BROMIC ULCERATION. 

and complete amnesia of attack. She was somewhat stupid from the bromide, 
but the amount given was impossible to ascertain. There was almost no 
facial acne; the child's color was clear and healthy. The mother, however, 
stated that since leaving the hospital clinic, the child's legs had become the 
seat of very painful sores, which she wished me particularly to examine. 
Bandages were removed from both the child's legs, and my surprise may 
be imagined when I beheld ulcers precisely like those of Miss C, seen a 
few months before. 

The lower part of each leg, some 5 cent, above the malleoli, was encircled 
by a large ulcerated patch distinctly elevated above the surrounding healthy 
skin. The outline of the sores was very irregular, varying in vertical width 
from 3 to 8 cent. ; the largest surface of each sore being on the fibular side of 
the leg. The edges were sharply defined and nearly vertical. The surface of 
the sores, raised 2 or 3 mm. above the healthy skin, was covered with brown- 
ish-black scabs and most offensive sanies. On removing some of these scabs 
a rough granulating surface, easily bleeding, was revealed. I use the word 
granulating, but the appearance was that of a firmer, more villous, in places 
almost papillomatous formation, than the delicate translucent and uniform 
surface of ordinary granulations. 

The mother, a not over-intelligent Irishwoman, stated that this local trouble 
began in April, Avhile using the bromide prescribed by the physician she con- 
sulted after giving up the hospital. At first the right leg was affected with 
large pimples or boils, which "broke," ulcerated, and coalesced into an open 
sore. In about a fortnight the left leg was similarly affected. It is interest- 
ing to note that this woman's account of the beginning of the ulcers agrees 
precisely with that given by the very intelligent mother of Miss C. 

I directed that the ulcers be gradually cleaned of scabs by frequent wash- 
ing, and that a strongly carbolized ointment be used twice a day. The dose 
of bromide of potassium was fixed at two grammes night and morning. The 
mother, having other children to attend to in the midst of the difficulties of 
tenement- house life, did very little toward cleansing the sores, and did not 
apply the ointment as carefully as necessary. Besides, the child dreaded to 
have the legs dressed, and cried violently each time they w T ere washed. I 
was away a great part of the time in the months of July and August, and 
during that time there was no material change in the size or appearance of 
the ulcers. The child remained free from ordinary bromism, and her com- 
plexion was good. The seizures occurred but rarely. 

On July 28th I gave her ether, and after removing nearly all the scabs from 
the left ulcer, I applied to it Paquelin's cautery quite freely, and ordered a 
carbolized lotion for a few days, to be followed by applications of balsam of 
Peru ointment. At the same time I cut out a strip of the ulcer and adjacent 
sound skin for histological study ; this was pinned on a cork and placed in 
bichromate of potassium solution. In cutting away this little flap I demon- 
strated that there was no appreciable lesion of the subcutaneous connective 
tissue; the derma seemed hypertrophied, but the whole piece was easily dis- 
sected away with the scalpel. I reduced the bromide one gramme night and 
morning, and gave five drops of Fowler's solution after each meal. 

I saw the child again Aug. 21st. The ulcer which I had cauterized — that on 



BROMIC ULCERATION. 633 

the left leg — was nearly half healed over; the right leg presented the same ap- 
pearance as at first, and in spite of my urgent orders, had not been well cleaned 
of scabs and sanies. I directed that to be done before the child was brought 
again, intending to use the cautery again, or to apply nitric acid. The same 
amount of bromide was to be taken night and morning, and eight drops of 
Fowler's solution was to be given after each meal. 

I have met with a third case, in which the legs were affected 
in a way not unlike what the mothers of Cases 1 and 2 describe 
as the first or carbuncular stage of the nicer ; and probably, if 
the bromide treatment had baen persevered with, ulcers might 
have formed in this case also. 

Miss A. B., aged 17 years, a handsome girl, with a very fresh complexion, 
of German parentage, consulted me on November 1, 1880, for epileptiform 
attacks. She was a healthy child. At 8 years had an attack of typhoid fever 
lasting several weeks. On getting out of bed at the end of eleven weeks, 
found that she could not walk. It was nearly spring (fever in August) before 
she walked freely. Arms were unaffected ; mind normal. In her ninth year 
had a convulsion one morning, biting her tongue. During the day legs 
became quite weak, especially the right. There seemed well-marked paraly- 
sis, but it is not certain whether there was any muscular wasting. Under 
galvanism and strychnia she gradually regained the use of her legs, but ever 
since she has had convulsions at very irregular intervals — every two or three 
weeks, or at intervals of months. In the last two years three or four severe 
attacks ; last one in September. Has had occasional doses of bromide, but no 
systematic treatment. Patient states that in night attacks she wakes dizzy, 
has time to call some one, hears a loud noise as of a wheel going faster and 
faster, until she loses consciousness ; hears no voices or bell-sounds. A cousin, 
who has witnessed seizures, says that there is a severe convulsion, in which 
patient's eyes are open; after attack, she is stupid, and wants to rise; talks 
and weeps violently. Then she falls into a heavy sleep. 

Last summer, was exposed to severe solar heat and had a profuse nose-bleed. 
Ever since has been liable to petit-mal; a whirling dizziness, followed by 
il faintings r in some instances. Further questioning shows that ever since 
first spasm she has had a third sort of attack, consisting in the sudden appear- 
ance of "balls before the eyes," followed by temporary diplopia; no drowsi- 
ness. 

In 1877, Dr. Brown-Sequard was consulted, and gave Miss B. his bromide 
mixture. This was faithfully employed for six months. The patient then 
had large sores with scabs upon her legs, mostly on right. It is difficult to 
ascertain whether these sores were like those described above, or discrete 
scabbed sores, such as I have seen in other patients, and termed rupia-like. 
There was no facial acne, and the epileptiform attacks were suspended. The 
bromides were stopped and the sores quickly healed. 

Examination showed some anaemia and symptoms of gastric catarrh. ' The 
case was so clearly epileptic, that in spite of the former bad effects of 



634 BROMIC ULCERATION. 

bromides, I persuaded the patient to try them again; giving her my solution 
of chloral and bromide,* three teaspoonfuls (twelve grammes), at bedtime, 
well diluted. Treatment and diet were also ordered for the gastric catarrh. 
In eight days a "boil" appeared on the right leg, constituting a small abscess, 
which ruptured spontaneously on the twelfth day, near a scar of the former 
eruption three years ago. D.ose of bromide solution reduced to two teaspoon- 
fuls at night. On the fifteenth day several large indurated pimples had 
appeared around the small abscess. On the nineteenth there was quite a crop 
of large purplish papules with evident tendency to suppuration on the right 
anterior region. This appearance, the patient said, was identical with that 
observed while using the Brown-Sequard mixture three years ago, and she 
begged me to stop the bromide. I might add that for a week or ten days 
arsenic and sulphide of calcium had been given to control the eruption. There 
was no bromism, hardly a trace of common facial acne, and the gastric symp- 
toms were better. 

I suspended the use of ordinary bromides, and gave bromide of zinc, bromide 
of camphor, digitalis, valerian, etc., at different times; also, at times, re- 
newed tonics and treatment for the dyspepsia. The epileptiform attacks 
have been almost perfectly under control, and there has been no return of the 
eruption (which passed away in a week or ten days after the bromides were 
withheld). 

Very probably, had I persevered in giving the solution of bromides, the 
papules would have all undergone suppuration and ulceration, coalesced, and 
formed an ulcer more or less like those observed in the other cases. 

The third case, though incomplete, has this value, that it 
bears out what the mothers of Cases 1 and 2 claimed as to the 
early appearances of the ulcers, viz. : at first an acne, undergoing 
suppuration and ulceration ; the resulting ulcers merging into 
one sore. 

The following points in the clinical history of these ulcers are 
interesting : 

1. Their origin in acne. 

2. Their progressive and semi-malignant tendency. 

3. The absence of bromism in the patient. 

4. The absence of slight development of common facial acne 
at the same time. 

5. The possibility of curing them by energetic local treatment 
(Case 1) without omitting the bromides. 

6. The inefficiency (?) of arsenic and of calcium sulphide 
(Case 3). 

Histology. — Sections of the piece of tissue removed from 
the ulcer show great increase in the thickness of the rete 
* Chloral hydrate, 15 ; potassium bromide, 30 ; water, 200 grammes. 



BROMIC ULCERATION. 635 

Malpighii, with hypertrophy of the whole skin in places. In 
several places villosities visible to the naked eye occur, made 
up of all the elements of the skin thrown up and out into a 
minute mushroom-like or polypoid mass. In othei places pro- 
liferation of young cells has taken place in the cutis, with atrophy 
and rupture of the epidermal layer, and partial escape of the 
newly-formed tissue, constituting a sort of abscess, opening 
externally. In other localities the patches of inflammation were 
wholly circumscribed, and sub-epithelial. The deeper layers of 
the skin, and to a certain extent the subjacent connective tissue, 
are infiltrated at certain points with young cells. The papillae, 
hair-follicles, and sweat-glands do not appear to be the seat of 
any primary or important inflammatory change. In no part of 
any section was its surface (edge) covered by granulation tissue, 
as in a common ulcer. 

From these appearances we may conclude that the ulcer 
resulted from a dermatitis, which was partly suppurative, but 
largely hypertrophic. 



A CASE ILLUSTRATING THE COINCIDENCE OF DIS- 
EASES: CERVICO-BRACHIAL NEURALGIA AND 
ANEURISM OF THE INNOMINATE ARTERY.* 

The influence of diagnosis, upon therapeutics and upon prog- 
nosis lias seldom been more strikingly shown in my experience 
than by the following case : 

Mr. S. S., aged fifty-two years, consulted me June 5, 1882, for 
a severe neuralgic ailment of the right side of the head, neck, 
and arm. He related the following history : Early in the summer 
of 1881, he had been thrown out of a carriage upon the sidewalk, 
but received no evident injury. After this fall he was restless 
and nervous, felt badly, had more or less gastric disorder. Spent 
the month of August in Saratoga, but was unrelieved. About 
that time he first noticed pain near the right olecranon process. 
This pain was quite localized at first, but soon later it extended 
toward the shoulder ; very gradually increased in extent and 
severity, occurring in more frequent paroxysms. Late in the 
autumn the shoulder region was involved ; and in December 
pain was felt in the head, a little to the right of the vertex, and 
later behind the right ear. Downward the pain has extended 
to the hand ; the fingers have never been painful or numb. The 
pain has been somewhat nocturnal, but never periodic. The 
patient has suffered extreme agony for months, pain extending 
from the right parietal region down the neck to the right shoulder 
and arm. No treatment until December, then for two months 
Mr. S. was under the care of a specialist for diseases .of the 
nervous system. Has recently been at the Hot SjDrings of 
Arkansas, where, with some internal treatment and applications 
of hot water in bags, he was somewhat relieved. Two weeks ago 
was subjected to strong electrical applications which greatly 
aggravated his neuralgia, particularly increasing the occipito- 
parietal pain. Since the electrical applications, the right arm 
has felt big and tight (not exactly numb). After paroxysm 
of pain the veins of the right arm appear full. A paroxysm 
occurs in my office, with chief acute pain behind right ear ; it 
is evident that the patient suffers extremely ; perspires during 
* From the Archives of Medicine, October, 1S82. 



NEURALGIA AND ANEURISM. 637 

the attack. Exertion, use of arms, or walking, causes increase 
of pain, or even produces a paroxysm. Fortunately no morphine 
habit has become established. No syphilis. 

Examination : Patient presents the usual facies of prolonged 
suffering ; is pale and thin. Seat of pain as above stated ; 
occipito-parietal, cervical, and brachial. Eight pupil a trifle 
larger than the left. Nerve trunks not tender, but painful regions 
are hyperaesthetic in paroxysms of pain. There is no paralysis, 
anaesthesia, or muscular atrophy ; the movements of the arm are 
free, except at the shoulder joint where some resistance and 
crepitation from false anchylosis. 

The right radial pulse is very feeble, much smaller than 
that on the left side. The right carotid pulse is likewise 
much smaller than the left. The right hand rs slightly swollen 
and tumid. 

There is no sternal or pectoral deformity, but the supra-clavicu- 
lar regions are both full, without yielding any unnatural pulsa- 
tion. The heart is rather large, and at its base is a rough 
double murmur, which can be traced upward to a point of max- 
imum intensity over the junction of the right second rib and 
sternum. No fullness or pulsation in supra-sternal notch. 
There is a slight hoarseness. Many of these points were deter- 
mined at a second examination. 

Taking into consideration the place of beginning of the pain, 
its distribution, and its typically neuralgic nature on the one 
hand, and on the other hand the absence of pain near the seat 
of intrathoracic disease, I made the double diagnosis of cervico- 
brachial neuralgia, and aneurism of the innominate artery. 
Contrary to what Mr. S.'s former medical advisers had said, I did 
not believe that his neuralgia was a sympathetic or reflex pain 
dependent upon the aneurism, and hence, incurable. I thought 
the coincidence a fortuitous one. 

Acting upon this belief, I at once began treatment by cauter- 
izing the neck with Paquelin's instrument, giving a deep injec- 
tion of morphia over the brachial plexus, and ordering 4. of 
Thompson's solution of phosphorus (equal to about .003 of 
phosphorus) to be taken every three hours. In forty-eight 
hours very great improvement had occurred; no pain in the 
head since cauterization, and only two paroxysms in the shoulder 
and arm. Several cauterizations were made ; morphia given by 
the mouth for a few nights ; the arm was kept quiet. In about 



638 NEURALGIA AND ANEURISM. 

two weeks iodide of potassium was substituted for the phos- 
phorus, and quinine also given. The neuralgia had almost 
ceased by the end of June ; but the whole arm felt queer, heavy, 
and swollen (semi-painful) ; the radial artery was smaller, the 
substernal dullness more marked, and the double murmur over 
the innominate artery louder. In other words, while the cer- 
vico-brachial neuralgia was nearly cured, the aneurism was 
making progress. 

Occasionally, there was slight return of cervico-brachial pain. 

On August 23d, Prof. Austin Flint corroborated the diagnosis 
of aneurism of the innominate artery, and suggested a trial of 
Tufnell's rest and low-diet treatment. This the patient has 
decided to submit to. He has no neuralgia (none to present 
date, September 8th) ; he is troubled by a severe cough, with 
bronchial catarrh ; his right arm is puffy and bluish, and feels 
badly. The local physical signs in the chest are the same. He 
takes quinine after breakfast, and a gramme of iodide of potas- 
sium in infusion of digitalis four times a day. 

I am led to publish this case because of the belief that had 
I looked upon the neuralgia as sympathetic and expended my 
therapeutic efforts upon the aneurism as the fons et origo mail, 
I should have also failed to relieve the patient. 



ANEURISM OF THE CCELIAC AXIS.* 

The specimen I present to-night was removed from the body 
of a sailor, 36 years of age, who died on the third of May, in 
the New York Hospital On admission, April 30, he gave the 
following history : 

Two months previously he began to suffer from rheumatic 
pains in the legs, arms, and left side of body, which pains had 
been decidedly nocturnal. The pain in the abdomen he located 
in the epigastrium, going through to the lumbar region, around 
the left hypochondriac space ; and he described it as very sharp 
and severe. He stated that until one month ago he never had 
anv dvspneea ; that he never had suffered from acute rheumatism 
or received any injury. Five years previously he contracted 
syphilis, and since has had secondary skin and throat symptoms. 
He had continued the duties of an able seaman during the first 
month of illness, but had after that time taken to his bed He 
noticed about three weeks ago that lying on his back caused 
increased pain. 

On being examined in the ward, he was found lying upon his 
right side, his knees drawn up, his face being pale and expressive 
of pain and anxiety. The tibia? and ulna? were found swollen 
and tender ; and the glands about the elbows and neck enlarged. 

Great tenderness was found in the abdomen over the left hypo- 
chondriac region, the epigastrium, and over the lower ribs near 
the spine. In the epigastrium a pulsation was distinctly visible, 
and on applying the hand a little firmly, a distinct aneurismal 
thrill was perceived. Ausculation showed the heart and arch of 
aorta free from abnormal sounds, but about 3. cm. above the 
ensiform cartilage in the median line, a loud, hard systolic 
murmur was heard. On tracing it downwards, it appeared 
loudest at the apex of the sternal appendix, getting fainter 
below that point until lost midway between the umbilicus and 

■ A specimen presented to the New York Pathological Society, May S, 1867. 
Reprinted from the New York Jltdical Record, July 15. 1867. 

This article is inserted here out of chronological order, being overlooked at the 
proper time, because it narrates a rare case and is on a kindred topic vrith the fore- 
going article. — [R. W. A.] 



640 ANEURISM OF THE CGELIAG AXIS. 

pubes. In the back no true murmur was to be heard, but a 
sort of shock or " thud," with the systole of the heart, was 
audible over the tenth dorsal vertebra-. No aneurism was to be 
found in any of the superficial arteries. A careful examination 
of the urine failed to reveal albumen or casts. 

The diagnosis was made of aneurism of the aorta in the 
neighborhood of the cceliac axis. Preparations were made to 
put the patient upon the postural plan of treatment, and mean- 
while morphia was given hypodermically to allay the pain. 
Unfortunately the issue was nearer than anticipated. On May 
3, at 1 p.m., the patient put his hand upon the tumor and fell 
into a fatal syncope. No imprudent movement had been made 
previous to this. 

The autopsy was made twenty-four hours post mortem. The 
abdominal cavity contained an enormous quantity of blood ; 
2 kilos, of clot, and 2,000 cc. of liquid blood. The heart and 
lungs were healthy. 

The aorta was removed as far as its division in the pelvis. The 
valves were healthy, but the vessel was extensively athero- 
matous ; in the arch anteriorly an aneurismal pouch had com- 
menced to form. Lower down, opposite the coeliac axis, no 
dilatation was to be found, the branches of the vessel arising 
in a normal manner. But on tracing out these branches, a 
large aneurism was found connected with the coeliac axis proper, 
adherent on the left to the suprarenal capsule, on the right 
to the lobus Spigelii of the liver, and above intimately con- 
nected with the diaphragm. The branches of the axis escaped 
from the lower part of the sac, whose walls, 1 cent, thick, were 
rough internally, made up of very old layers of fibrin; the 
rupture having taken place (an opening 1 cent, across), at the 
anterior edge of the adhesion with the liver. The sac con- 
tained but a little liquid blood and clot. The remaining ab- 
dominal vessels were healthy. 

The spleen, liver, and kidneys were healthy. The physical 
signs in the case are remarkable, and might have been sufficient 
for the making of an exact diagnosis. There was no doubt as 
to the height of the aneurism, and dilatation of the aorta 
might have been excluded on account of the absence of the 
of bruit in the back. It is very remarkable that the patient 
had never suffered from vomiting or any disorder of the diges- 
tive organs excepting constipation. 



HYSTEKICAL CONVULSIONS AND HEMIANESTHESIA 
IN AN ADULT MALE: CURED BY METALLO- 
THERAPY (GOLD).* 

Examples of hysterical convulsions in the male sex are rather 
frequent in youth and boyhood, but after twenty they become 
so rare as to be worthy of record. Still more unusual is it (in 
this country at least) for hemi-anaesthesia to follow the succes- 
sion of convulsions. For these reasons, and because the case 
presents points of interest as regards diagnosis and therapeutics, 
I desire to place it before the readers of the Archives. 

James A., 21 years old, single, and a laborer by occupation, 
was brought to the Manhattan Eye and Ear Hospital by Dr. 
Smith, of Newtown, Ct., for the diagnosis and treatment of an 
alarming set of nervous symptoms, briefly summed up as con- 
vulsions, extreme staggering, left-sided hemi-anaesthesia. 

History. — A year ago the patient fell from the upper platform 
of a freight car, a distance of at least ten feet, striking the ground 
upon the back of his head. He thinks that he was unconscious 
for a few minutes, but did not vomit. Remained well after this 
fall until some six weeks ago. Denies sexual excesses or irregu- 
larities. At that time, some six weeks ago, he had an ill-defined 
illness — apparently a severe " cold," characterized chiefly by 
pains all over his body, in the muscles mostly. Thinks that he 
had no fever (locality is malarious, however), and is positive that 
he had no articular swelling or sore throat. The account of the 
order of appearance of the nervous symptoms is obscure, as Dr. 
Smith did not see patient until two weeks ago. Then had 
already had several " fits," apparently of an epileptic nature ; 
he was not paralyzed, but exhibited complete insensibility to 
pricking on the left side of his head, face, tongue and body. He 
also staggered somewhat. He complained of headache, near the 
vertex and over the right parietal region. Convulsions occurred 
every night ; and one night about ten days ago there were several, 
which were witnessed by Dr. Smith. In these attacks the patient 
was stiff; eyes closed, showing, when the lids were raised, 
normal pupils ; the respiration was slow and gasping ; the spasm 

* From the Archives of Medicine, Oct. , 1882. 
41 



642 ANESTHESIA CURED BY MET ALLOTHE RAPT. 

was only tonic, and lasted, quite certainly, not less than three 
minutes. There was no frothing of the mouth, or subsequent 
drowsiness. The patient claimed not to know anything of these 
seizures ; attacks occurred yesterday. A friend of the patient 
describes attacks lasting an hour and a half. The staggering 
gradually increased during the fortnight of observation ; clear 
(colorless ?) urine was often voided ; no globus or emotional 
seizures ; has seemed rather obtuse or stupid. Much bromide 
of potassium has been administered. At first he had 2.75 
every four hours., and later every two hours, and loss often. 
Altogether has taken about 45 grammes in ten days. 

Examination. — Patient is an average, dull-looking Irishman, 
generally pale, and with the neurotic white circle about his 
mouth strongly marked. Comes into the room supported by 
two persons ; staggers preposterously ; when not supported 
plunges off to one side or the other ; no paralysis ; sees and 
hears well (to simple tests) ; pupils normal ; left side of body, 
face and tongue presents complete analgesia. Ends of fingers are 
a little sensitive to deep pricking (only in last two or three days). 
The various modes of sensibility and the special senses were not 
critically studied, because we purposed doing this on another 
day. To watch-test and to ordinary objects there was no deafness 
or blindness of the left ear and eye. An interesting experiment 
was made upon the patient as regards his equilibrium. I placed 
him in the middle of the room, loosened his friend's hold of his 
arm, and told him to look up at the ceiling and try to see certain 
fine marks upon it. Thinking that I was testing his eyesight, he 
strongly directed his attention that way and stood perfectly well, 
without a trace of his staggering ; which, however, returned the 
moment that the test was over and he was told to stand alone — 
that he could not do (while thinking of it). 

Without saying anything to the patient or to the physician 
and students standing by, I applied two twenty-dollar gold 
pieces to the patient's left hand, and afterward to his forearm, 
cheek and tongue. I most positively said or did nothing which 
could suggest anything to him. He could not tell whether I meant 
this as a continuation of the examination, or as a remedial meas- 
ure ; he looked and spoke as if he thought I was amusing myself 
in applying the gold. 

In a few moments, one to three minutes, sensibility returned 
in each part where the metal had been laid ; completely so in 



CONVULSIONS CURED BY METALLO TREE APT. 643 

the tongue, and partially in the cheek, forearm and hand. The 
patient was amazed. I ordered a capsule containing .30 of citrate 
of iron and quinine, and .01 of extract of nux yomica, to be 
taken four times a day. 

The next day, September 21st, the patient was examined by 
my colleague, Dr. W. K. Birdsall, who found him nearly free 
from staggering; pricking with a needle was felt a little less 
than normally on the left face, quite normally on the left arm 
and hand. On the left leg (not yet treated) pricking was 
somewhat felt, but simple touch was not perceived. A belt 
of gold plates was applied round about the calf for ten minutes, 
when sensibility was found to be restored, not simply where the 
plates had been laid, but throughout the extremity. On neither 
day was any phenomenon of " transfer " observed. 

On Sept. 23d patient, claiming to be perfectly well, left the 
hospital, contrary to my request. 

The diagnosis of the case presented but slight difficulties, in 
spite of its extreme rarity. The staggering was evidently over- 
done, or at least greater than in any organic or functional cere- 
bral disease known to me ; and it was made to cease by diverting 
the patient's attention in an interesting manner. The convul- 
sions were too long to be anything but hysterical, and the 
state of the pupils indicated the non-epileptic nature of the 
seizures. The continuation of the symptoms — nay, their aggra- 
vation — under severe bromide treatment was in accordance with 
my own experience in hysterical cases. 

The brilliant success of metallo-therapy in this case is inter- 
esting and very puzzling. I believe that every physician present 
when the gold was first applied, will agree with my statement 
that there was no sort of suggestion made to the patient — nothing 
was said until after the patient himself looked up in amazement 
at the restoration of sensibility to his hand and tongue. 

It might be added that in the last two years I have had sev- 
eral successful cases of metallo-therapy in my practice — all of 
them reactions to gold. One of the most striking was that of 
a girl aged about sixteen, showing decided chloro-ansemia, but 
free from hysterical symptons except analgesia of the whole left 
upper extremity, and the neurotic white circle about the mouth. 
In this case an elongated oval area on the extensor surface of 
the forearm remained analgesic in spite of several short appli- 
cations of the gold, but yielded to their continued contact for 
twenty-four hours. 



TWO CASES OF GLYCOSUBIA; ONE TKUE AND ONE 

SIMULATED.* 

The two following cases are presented because they are both 
in some way unique. 

Case I. — Mrs. consulted me in October of this year for simple, moder- 
ate dementia. She was fifty-one years old, and had masturbated for years. 
Six years ago she had an attack of quite acute melancholia. 

In the last three years marked emaciation had taken place. No positive 
delusions or hallucinations seemed to exist. The memory had been fairly 
retained. 

The patient fancied that her shoulders were paralyzed, and wanted to have 
her arms cut off. There existed no actual paralysis. The patient's manner 
was demented and hypochondriacal. She had no symptoms of diabetes ex- 
cept emaciation, hence it was not suspected. 

As a matter of routine her urine was examined with the following result : 
An afternoon specimen had the specific gravity of 1,045, and contained a 
trifle over five per cent, of sugar, but was otherwise normal. A specimen 
passed the next morning had the specific gravity of 1,018, and did not con- 
tain a trace of sugar. 

Oct. 14th. — Two days later, a morning and night specimen were sp. gr- 
1,020 and 1,011 respectively, and contained no sugar. 

Oct. 16th. — The urine had the sp. gr. 1,019 and 1,023, and was free from 
sugar. 

Oct. 21st. — Four specimens were found of normal specific gravity and re- 
action. When last heard from (about November 12th) the patient was doing 
well and had no symptom of diabetes. The patient had neither medication 
nor diet which could have caused the sudden disappearance of sugar from the 
urine. 

Cases of mild diabetes are not rare where an occasional sample of urine is 
found devoid of sugar; but a fall in the specific gravity from 1,045 to 1,018 
and from five j)er cent, of sugar to none in twenty-four hours, is by no means 
common. 

How long the patient had been passing sugar cannot be told, and we may 
perhaps look on the case as one where some peripheral sensory impression or 
some transient central alteration produced a disturbance of the chylo-poietic 
circulation which interfered in proper glycogenesis. This is rendered more 
probable because Pavy, Cyon, Aladoff, Schiff, and Eckhard have shown that 
irritation or destruction of many parts of the peripheral nervous system will, 
in a reflex way, produce glycosuria, while by puncturing the floor of the 

* Reprinted from the Archives of Medicine, Vol. viii., No. 3, Dec., 1882. 



TWO^ CASES OF GLYCOSURIA. 645 

fourth ventricle, Bernard long ago caused sugar to appear in the urine of 
animals. Among diabetics, too, a profound mental or bodily shock almost 
invariably causes an increased excretion of sugar. 

Case II. — In May of this year an old patient of mine sent three specimens 
of urine, with the request that they should be thoroughly examined. He 
said they were passed by a niece of his, who was under the care of a homoe- 
opathic physician for some hysterical affection. More definite data than 
these it was difficult to obtain. A night specimen of May 18th was pale, 
cloudy, contained some uric acid, and a trace of sugar. It had the sp. gr., 
however, of 1,070! A specimen passed the next morning contained only a 
trace of sugar, and had the sp. gr. of 1,048. A noon specimen of that day 
was pale, poured like syrup, and, with only about three per cent, of sugar, 
had the sp. gr. 1,090! 

Besides these examinations, which were made by Dr. Amidon, I sent the 
heavy specimen to Mr. Charles Rice, of Bellevue Hospital, and the following 
is an extract from his letters in reply : 

"There is, however, something present which I cannot make out exactly, 
but which I have separated and find to resemble in some of its properties 
'peptone,' or digested albumen. If a portion of the urine is mixed with about 
five times its volume of absolute alcohol and shaken, a gummy substance 
separates, which may be caused to agglutiuate into a lump by judicious turn- 
ing of the test-tube. After being washed with alcohol it is found to be 
but little soluble in boiling water, but it dissolves in cold water, particularly 
after addition of a drop or two of hydrochloric acid, to a very thick, almost 
colorless, faintly opalescent liquid. It gives no reactions with nitrate of 
silver, or mercuric chloride, and does not exhibit any reactions of the ordinary 
gums." 

June 6th. — Two more specimens Merc procured and examined by Dr. Amidon 
and Mr. Phelps. A night specimen was clear, pale, and gave a faint sugar 
reaction. It was syrupy, and had a sp. gr. of 1,105! A morning specimen, 
while it seemed to contain less sugar, had a sp. gr. of 1,117!! A fraud was 
immediately suspected, and its detection was attempted. 

Mr. Rice kindly examined the latter specimen and said: "The last speci- 
men of 'urine' seems to contain but little genuine urine, to judge from the 
small amount of the sulphates, phosphates, chlorides, and urea present." "It 
contains a body (or mixture of bodies) insoluble in alcohol, and partaking of 
some of the properties of starches and of gelatin, without, however, giving a 
reaction for starch itself, or a definite reaction for gelatin." "I should say 
the thing is a fraud." 

A series of experiments were then made with gelatin, cane sugar, and vari- 
ous syrups. It was finally found that a mixture of a fine sorghum syrup and 
urine, in such proportions as to bring the specific gravity up to about 1,115, 
produced an exact imitation of our puzzling specimen. It gave the same pre- 
cipitate to absolute alcohol, and contained the same amount of grape-sugar. 
It was, moreover, found by Dr. Amidon, that on standing and fermenting the 
cane sugar was transformed into glucose and gave a magnificent reaction to Fehl- 
ing's test, while, when fresh, only a faint sugar reaction w T as obtainable. Also 
it was noticed that the specific gravity of the specimen of June 6th, which 



646 TWO CASUS OF GLYCOSVRIA. 

had stood in the laboratory uncorked for ten days, had fallen from 1,117 to 
1,010, showing that the cane sugar had fermented and disappeared. 

The mother of the patient was asked to see some urine passed in a clean 
vessel and send it for examination. 

It was some time before this could be brought about, but at last a night 
specimen of urine was sent in which was clear, of a reddish-yellow color, 
acid, free from albumen and sugar, and of the specific gravity of 1,024. 



NOTE ON CEANIO-CEBEBEAL TOPOGEAPHY. ILLUS- 

TBATED.* 

The surgical anatomy of the head, with reference to its con- 
tents has been developed with remarkable completeness within 
the last ten years, chiefly by the researches of Broca, Bischoff, 
Heftier, Turner, and Fere, by which cranio-cerebral topography 
has been firmly established as a branch of practical anatomy. 
Acting upon the data thus obtained, Broca, Lucas-Championere, 
Weir and others t have successfully trephined for the relief of 
aphasic and paralytic symptoms. The location of many convo- 
lutions and fissures of the cerebrum can be accurately mapped 
out upon the surface of the skull, or even upon a living head, by 
the projection of certain lines and measurements from certain 
points thus obtained, as well as from some natural landmarks. 

For the projection of these lines, the head is placed in a 
particular position, as can be easily done when we operate 
upon a bare skull ; but which can also be approximated when 
we deal with a living subject, either sitting up or lying in 
bed. The skull or the shaven head should be so placed and- 
held that a line passing from the alveolar process of the superior 
maxilla just at the insertion of the teeth, and through the lowest 
part of the occipital bone, shall be horizontal. The greatest 
care should be used to determine this line — the.alveolo-condy- 
loid line or plane of Broca, — for it is upon it that all other 
projections and measurements are based. In the annexed figure 
the skull is represented as resting upon the alveolo-condyloid 
plane, 1-1. 

Next, from the alveolo-condyloid line a vertical line, or one 
exactly perpendicular to the first, is drawn through the external 
auditory meatus. At the top of the head this line — the auriculo- 
bregmatic line, — A- A, indicates the bregma or true vertex, which 
is an important landmark, one which should be traced with ink 

* Written for Gross' System of Surgery. Reprinted from the Archives of 
Medicine, Vol. viii, No. 3, December, 1882. 

f See a recent contribution to the subject by Prof. H. B. Sands, " The Question of 
Trephining in Injuries of the Head." (X.Y. Medical Journal, April 21st, 1883.) 



648 



CRANIO-OEREBRAL TOPOGRAPHY. 



or carmine upon the shaven scalp. Upon the top of the head 
or skull an imaginary horizontal line, 4-4, parallel with the 
alveolo-condyloid plane, is projected, and upon this line, 4-4, we 
measure backward 50 mm. and draw a second vertical line, B-B, 




Fig. 1. 



Topographical lines applied to the external contour of the head. 

parallel to the auriculo-bregmatic line. At the place where this 
line strikes the convexity of the head is the Eolandic point, E, 
under which, in average heads, lie the upper or posterior 
extremity of the fissure of Bolando, the upper ends of the ascend- 
ing frontal and ascending parietal convolutions, and, within the 



CRANIO-CEREBRAL TOPOGRAPHY. 



649 



longitudinal fissure, the paracentral lobule ; in other words, the 
upper part of the motor area of the cerebrum, that which quite 
probably controls the volitional movements of the legs. The 
Eolandic point, thus determined, should, on a living subject for 
operative purposes, be properly marked upon the shaven scalp. 
A third horizontal line is next to be drawn from the external 
angular process of the frontal bone, parallel with the alveolo- 
condyloid plane. This line, 2-2 — which may be called the fronto- 
lambdoidal, as its posterior extremity will usually pass at or 
near the upper angle of the lambdoidal suture — serves the pur- 
pose of determining the situation of some important parts. In 
the first place the line 2-2, passes about 5 mm. above the upper 
border of the squamous suture, and under this line, mostly parallel 
to it, are the anterior two-thirds of the fissue of Sylvius. Secondly, 
at about 5 mm. above and behind the intersection of lines A-A 
and 2-2 is the inferior extremity of the fissure of Kolando 




Topographical lines applied to Henle's skull. Location of the Eolandic fissure, motor centres, 
and branches of the middle meningeal artery shown. 



bounded by the ascending frontal and -ascending parietal convo- 
lutions. In the third place, upon this line, 2-2, at a .distance of 



650 CRANIOCEREBRAL TOPOGRAPHY. 

18 or 20 mm. behind the external angular process of the frontal 
bone, is the folded part of the posterior extremity of the third 
frontal convolution, or Broca's speech-centre, marked F 3 on the 
diagram. 

Having exactly determined and marked the situation of the 
Rolandic point at the top of the skull, and the inferior termina- 
tion of the fissure of Rolando above the ear, these two points 
are connected by a line which is represented darkly drawn upon 
the diagram. This, the Rolandic line, is the guide for nearly all 
operations intended for the relief of traumatic spasm or paraly- 
sis, since under it and near it lie the so-called motor centres for 
different parts of the body on the opposite side, as determined 
by experiments upon monkeys and dogs, and by numerous post- 
mortem examinations made in cases of tumors and other limited 
lesions of the brain. 

As indicated by the dotted lines on the diagram, the motor 
zone or centre for the lower extremity of the opposite side lies 
about the Rolandic point, making an allowance of at least 10 
mm. to either side of the median line for the interval between 
the two hemispheres. It also includes the paracentral lobule 
within the longitudinal fissure ; and we are led to believe, from 
observation in cases of cerebral tumor, that this part is preemi- 
nently the centre for the leg. Below this, reaching quite down 
to the fronto-lambdoidal line 2-2, is the motor area of the upper 
extremity. Forward of this, between the auriculo-bregmatic 
line A-A and the line C-C, is a part of the second frontal con- 
volution, which probably has connections with the facial muscles 
of the opposite side. Finally, at F 3 is the speech-centre of 
Broca, which although not now regarded as the only speech- 
organ, yet plays an important part in the simpler mechanism 
which produces language-motions. 

Other relations of interest are the apex of the sphenoidal or 
temporal lobe a little beneath the line 2-2, and at about 10 or 
12 mm. posterior to the external angular process of the frontal 
bone ; the situation of the occipito-parietal fissure almost imme- 
diately under the posterior end of the line 2-2, at its junction 
with the vertical line E-E, which also indicates the posterior 
extremity of the cerebrum ; the anterior end of the brain is 
marked off by the vertical line D-D. Furthermore, for certain 
purposes, the limits of the central ganglia of the brain may be 
estimated as follows : Their superior limit is indicated by a hor- 



CRANIO-CEREBRAL TOPOGRAPHY. 



651 



izontal line or plane drawn at a level 45 mm. below the vertex, 
line 3-3 of the diagram ; their anterior limit, which corresponds 
to the head of the nucleus caudatus, is traced by the vertical 
line C-C; and their posterior limit, or hinder end of the thala- 
mus opticus, by the vertical line B-B. Lastly, it may be stated 
that the angular gyrus — a part of the cortex which recent 
autopsies would seem to connect with vision — lies not far from 
the point of intersection of the lines B-B and 3-3, at the point 
marked A on the diagram. This, in the living subject, is a little 
below and behind the parietal eminence. 




Fig. 3. 

Topographical lines and landmarks projected on the convolutions, the apparent non-conformity of 
theRolandic line and fissure being due to perspective. Henle's skull. 



The location of the middle meningeal artery, which so often 
furnishes the blood which compresses the brain after various 
injuries of the head, is surgically considered of great importance. 
The course of the two principal branches of the artery is 
approximately indicated upon Fig. 2 by the branching lines 
drawn on the anterior, inferior angle of the parietal bone. 



652 CRANIO-OEREBRAL TOPOGRAPHY. 

In the living subject, the main trunk of the artery would be 
found under the horizontal line 2-2, at a point a little pos- 
terior to the speech-centre, about 30 mm. behind the external 
angular process of the frontal bone, and in front of the beginning 
of the fissure of Sylvius. It passes obliquely upward and back- 
ward almost immediately over the whole of the ascending frontal 
convolution, from 5 to 10 mm. in front of the Rolandic line. The 
inferior branch of the artery is mearly horizontal, and almost 
exactly overlies the fissure of Sylvius. 

Upon the shaven head of a patient, seated in a chair or lying 
in bed, the principal landmarks and relations above defined can 
be mapped out with a great approximation to accuracy by the 
use of two rulers, or even by one, to mark the alveolo-condyloid 
plane, and a card-board cut so as to stand astride the skull in 
the auriculo-bregmatic vertical. A light wooden apparatus 
could be easily made to indicate these two lines, while the 
remaining measurements could be taken with a tape, and the 
points marked with carmine or black ink. 

The practical utility of these anatomical data depends upon 
an acceptance of modern physiological teaching upon the 
subject of the functions of the brain. The experimental and 
pathological evidence now accumulated in favor of the con- 
nections of the " centres " marked on the diagram and certain 
peripheral parts, and between the whole of the motor area, and 
the whole opposite side of the patient is, as we look at it, 
convincing, and leads us frequently to a very accurate topograph- 
ical diagnosis in medical cases. 

The following operations may be referred to as illustrative 
of the utility of the laws of cerebral localization and of cranio- 
cerebral pathology : 

Broca, in 1871, in a case in which aphasia and paralysis 
followed a severe lacerated scalp wound, trephined over the 
left third frontal convolution, or speech-centre, found pus, and 
slightly relieved his patient. 

Lucas-Championniere, in 1874, trephined a man in whom 
coma, partial right hemiplegia, convulsions, and, as shown 
during convalescence, aphasia resulted immediately from a 
slight cranial injury. There was only a slight scalp scar to 
guide him, but he came in contact with splinters and blood 
from a fracture existing below the point of apparent injury, 
and saved his patient. 



CRANIO-CEREBRAL TOPOGRAPHY. 653 

Hueter, of Greifswald, in 1879, in a somewhat similar case, 
trephined the skull, ligated the middle meningeal artery, and 
cured his patient. In another case in 1870 he was equally 
successful. 

Courvoisier trephined, in 1878, a child two and a half years 
old, who, after an insignificant wound, in the left temporal 
region, had right hemiplegia, coma, and palsy of the left side 
of the face. He found a fissured fracture, and pus outside 
the dura mater as well as a large quantity under it. The 
operation was followed by recovery with weakness of the 
right side. 

Dr. R F. Weir, of New York, in 1882, operated at Bellevue 
Hospital, in a case in which coma and slight hemiplegia 
existed, the patient being a man who had received a blow on 
the head. There was no very evident external injury, but 
guided by the various data of cerebral localization, and 
proceeding according to the rules of cranio-cerebral topography, 
the trephine was applied, and a small clot found between the 
brain and dura mater. On incising the latter the brain was 
seen to be extensively disorganized, and the seat of copious 
hemorrhage, which was checked by torsion. Although the 
symptoms were relieved by the operation, death occurred 
within a few days. For an account of Dr. Sands' case 
see N. Y. Medical Journal April 21st, 1883. 

Up to the present time, so far as we know, there are only 
four cases in which the rules of cranio-cerebral topography 
have been applied, from measurements actually made prior 
to operation. These cases occurred in the practice, respec- 
tively, of Broca, Lucas-Championniere, Weir and Sands. There 
are probably other examples, but we are unable to particular- 
ize them. However this may be, there is a large number of 
recorded instances of relatively or absolutely successful 
operations performed after cranial injuries, for immediate as 
well as for secondary effects, without measurements. 

The indications for trephining after cranial injuries for the 
relief of symptoms of cerebral irritation, compression, or 
disorganization, may be provisionally stated as follows : 

1. When aphasia supervenes immediately or within a few 
days or weeks after an injury to the anterior portion of the 
head on the left side. It is extremely probable, in the first 



654 CRANIO-GEREBRAL TOPOGRAPHY. 

case, that a clot or bony spicule will be found compressing 
the speech-centre ; and in the second, that an abscess has 
formed either in the same part or close to it. 

2. "When simple hemiplegia, or hemiplegia with hemi- 
spasm, follows an injury, however slight, in the temporo- 
parietal region. If the spasm or paralysis be limited to one 
limb or to the face, the indication to operate is even 
stronger. Even if the injury be not directly over the motor 
area, the surgeon is justified in such a case in exploring that 
area. 

3. In conditions of coma after cranial injuries, sometimes 
without external wound, in which meningeal hemorrhage is the 
cause of death, the discovery of slight hemiplegia should 
call for trephining planned according to the rules above 
laid down, as in Weir's case. A latent hemiplegic state may 
be discovered, at least in some cases, by an increase of periph- 
eral temperature, as of the fingers or toes, on one side, and by 
the presence of congestion or of an erythematous blush on one 
buttock. 

4. In the very rare cases in which the paralytic phe- 
nomena are found on the same side of the body as the cranial 
injury, it might be proper to trephine on the opposite side 
of the skull in search of hemorrhage or fracture, the result 
of contre-coup. 

5. In chronic epilepsy after traumatism of the head, the 
indication for operation is present, but it is not a specific 
indication, connected with the subject under consideration. 
A lesion of any part of the skull may be a cause of epileptic 
attacks, irrespective of the motor centres. 

Contra-indications to trephining may be thus enumerated : 

1. Whenever in apparently favorable cases there are signs 
indicative of lesion of the base of the brain, such as palsy 
of several cranial nerves, neuro-retinitis, or Cheyne-Stokes 
respiration. 

2. When hemiplegia is accompanied by great anaesthesia, 
rendering it probable that the lesion is beyond the motor 
area, deeper, and farther back. 

It should be understood that these indications and contra- 
indications are formulated from the stand-point of the neuro- 
logist. The surgeon, upon general grounds, will doubtless 
often modify them, and add others. 



THE TEEATMENT OF MILD CASES OF MELANCHOLIA 

AT HOME.* 

Gentlemen: The little patient now before you is the sub- 
ject of a very rare disease — Intermittent Melancholia. He has 
been under my observation and treatment for about fifteen 
months. The history of the case, condensed from numerous 
notes made during that period, is as follows : 

Agie Van R , aged 11 years, is the child of poor parents who have not 

had insanity or other nervous disease: they are simply ill-nourished and small. 
Agie himself enjoyed good health until, in the winter of 1873-4, he injured 
his head by falling backward from a stoop. The scalp was cut through at a 
point midway between the right ear and the occipital protuberance. The 
blow was severe enough to produce loss of consciousness lasting several min- 
utes. No symptoms followed this injury, and its occurrence was not remem- 
bered by the mother until long after the mental affection had manifested 
itself. At the time of the patient's first appearance at my clinic, Dec. 19th, 
1874, the following notes were made in the clinic record: u TVas perfectly 
well to July 12th. Had been out in the sun; fell asleep, and slept nearly 
half the time for two days. He was out of his head ; restless ; singing sense- 
less songs; eating everything; was cross; recognized everybody ; complained 
of headache; could not walk straight. In two weeks became entirely well. 
After an interval of two weeks, he had another attack in which he was 
sleepy and out of his mind. Probable hallucinations of vision in this second 
attack. For some time had such attacks regularly on the fourteenth day, 
lasting fourteen days. Agie states that in attack before the last (October) 
he thought he saw bears and thieves entering the room. Last month was 
treated by Dr. Woolsey Johnson, in Professor A. Clark's clinic, with quinia, 
obtaining an interval of four weeks. Present attack began on Dec. 13th. 
Is drowsy, restless, and wants to lie down; many parts of the body are the seat 
of twitching. Is dull, and speaks slowly when questioned; denies headache; 
is cross; lies in his mother's lap; pupils normal; sulphate of quinia to be con- 
tinued. The attack terminated Dec. 24th, and he was then given .001 grain 
strychnia twice a day, and the mother was directed to apply the wet-sheet. 
This treatment did not prevent the return of attacks, in January and Feb- 
ruary, 1875. 

" February 8th. — Was well up to yesterday noon, then was rather low. 
At supper, "fainted dead away" (fit?) and vomited afterward. To-day, looks 
anxious and depressed: eyes have lost brightness; he slept, but has been 

* Reprinted from A Series of American Clinical Lectures, vol. ii. no. iii, 1876. 



656 TREATMENT OF MELANCHOLIA AT HOME. 

singing this morning. Pulse, 90. Ordered bromide of ammonium, .30 
and bromide of potassium, .60 every four hours. Feb. 10th. — Has a 
depressed, sad look; is restless; whistling, chuckling, mimicking, singing. 
Restless last night. Fundus of eyes normal. Only complaint is of pain in 
right hinder part of head, and some dizziness. Feb. 15th, eighth day of 
attack. — Is depressed, noisy, and ill-behaved; pulse, 90. Ordered stop 
bromides, and take strychnia again, and a teaspoonful of whiskey, several 
times a day. Feb. 22d.— -About well; wants goto play. March 9th. — Mel- 
ancholia appeared again yesterday; is depressed, and looks pale; not noisy. 
Pressure on cicatrix in right occipital region, causes a bad feeling in stomach. 
March 10th. — Patient is etherized, and an incision is made through the scar 
down to the bone, and a pea put in. Cicatrix is found whitish and tough, 
adherent to thickened periosteum. Father states that in fainting fit of Feb- 
ruary 7th, the boy's face twitched, and he lost consciousness wholly. This 
statement is to be received with much allowance. March 11th. — No worse; 
still dull and anxious-looking; not noisy. Dressing of wound, while not 
causing much pain, produces bad feeling in stomach ; faintness ; at first 
flushing of the face, then pallor; no twitching or loss of consciousness. The 
strychnia w^is stopped a few days ago and the bromides resumed, with 
whiskey. March 19th. — Coming out of an attack; wound is still open (pea 
dressing), and a pressure on it is felt in the stomach. March 22d. — Since 
yesterday morning has been bright and quite himself. Dressing of sore on 
head produces pallor, sweating, temporary loss of consciousness. Takes 
iodide of potassium, 1.20, three times a day. April 5th. — On the 3d, awoke 
irritable and queer; interval a little less than fortnight; yesterday, slept 
much, ate a great deal, whistled, and sang. General dread without hallu- 
cinations ; will not go into room alone. Sore is allowed to close up. Ordered 
bromides of ammonium and potassium, . 30 of former, . 60 of latter, thrice a 
day, a double dose at bed-time. Pulse weak and irregular, about 75 ; tongue 
clean. " 

During an attack beginning May 3d, the bromide treatment was abandoned 
and opium given in doses of .015, four times a day, to be gradually in- 
creased to six and seven times, if no drowsiness appeared. ' ' May 7th. — 
Yesterday, was noisy at times; to-day, is quiet and respectful in my offiee. 
This morning asked for newspaper, and read the news to his mother; when 
he is well he does not care to read a paper. Continue the opium, .015^ six 
or seven times, food and stimulants ; pulse, 75. May 1 3th. — Is much better ; 
dressed himself, walked out alone yesterday. Curiously, he has slept less in 
the day-time since taking opium; yesterday, was not at all drowsy. To 
have opium .03, four times a day. May 16th. — Perfectly well; attack 
lasted only eleven days, and was very light. Continue opium, food ; cod-liver 
oil in one dose. May 27. — Remains well. Continue treatment. June 14th. 
— Has been well for nearly five weeks; looks and feels well; has taken 
.12 of opium a day, regularly, and began to feel its soporific effect only on 
the 10th and since. Lately has had no cod oil. To resume oil and take less 
opium, .03, thrice a day for a week, then twice a day. June 17th. — Was 
well, up to 1 p.m., yesterday. At 2 p.m. was found by his mother sleepy and 
taciturn ; slept all the evening. No physical or moral cause of attack can be 



TREATMENT OF MELANCHOLIA AT HOME. 657 

discovered. To-day has usual depressed, anxious look, is not noisy, lias no 
hallucinations; tongue is clean; pulse, 93. Ordered opium, .03, five and 
six times a day. June 19th. — Not as noisy as in previous attacks. No 
effect from pills, though he takes seven a day. July 17th. — Has been well for 
three weeks and three days." I made no note of the case during July and 
August. "Oct. 19th. — Was well eight weeks yesterday. To-day, mild 
depression ; is not noisy. A fortnight ago, took opium for a week in small 
doses. .Has had cod-oil more or less regularly. To have opium .03 five 
or seven times a day, according to effect. Oct. 27th, tenth day of attack. — 
Is brighter and better ; sleepy from opium. In this attack was not at all 
noisy; wept at times. Ordered continue two opium pills a day; also strychnia 
.001 in Horsford's acid phosphates." 

During the later autumn and during the last two months, Agie has had 
long intervals of health, ranging from nine to five weeks, and has had but 
three attacks. He is now emerging from one. During January, he took 
fluid extract of ergot, 2.gm., four times a day, and last month Thompson's 
solution of phosphorus 2.gm., thrice a day. Cod-liver oil has not been used 
since the new year. On the whole, very great progress has been made in the 
case, especially if we take into consideration the bad surroundings in which 
the little fellow has been placed: his insufficient food, and various depressing 
moral influences in his home. Many months ago I urged his mother to place 
him in an asylum, but she preferred to run the chances attending a treatment 
at home. It is remarkable and gratifying that, in spite of such numerous 
attacks of melancholia, no dementia has developed. 

In connection with this case, I would ask your attention to several con- 
siderations of aetiology and treatment, though, before doing this, I ought to 
present a summary of the symptoms exhibited by our patient. Naturally, and 
when well, he is a very bright, cheerful, and intelligent little fellow; with brill- 
iant eyes, red cheeks, and strong lines of character in his face. His deport- 
ment is unusually good, and his politeness remarkable for his station in life. 
He is, I am told, very affectionate, and attentive to his mother and sisters. 
During an attack, he is entirely metamorphosed. His face is drawn, and sad; 
the light has left his eyes, and the color almost departed from his cheeks; his 
attitude is relaxed and careless, his dress is disordered, his hair uncared for. 
His good manners have vanished; he keeps his hat on in my office, asks for 
fruit while waiting in my dining-room, whistles, kicks the furniture, answers 
questions reluctantly and in a cross way. At home, he does not stir from a 
corner or chair, will not rise from the bed, or dress himself, unless forced to ; 
is ravenous and noisy. He has several times had hallucinations of sight, never 
of hearing. He has (not in every attack) complained of pain or dizziness in 
the head. Once he fainted (twitched?) at the beginning of an attack. His 
digestive organs have always been in good order. He has been both drowsy 
and sleepless in different attacks. I took his temperature many times, and 
found no deviation from the normal standard; the pulse has ranged from 68 
to 100, and I was never able to make out a regular rise in its frequency 
during attacks; though, on the whole, it has then seemed to range higher. 
Pallor and some emaciation were present, last year. I caused him to be 
closely watched for epileptiform seizures, without result. 



658 TREATMENT OF MELANCHOLIA AT HOME. 

As regards the mode of production of the attacks, I have thought of sev- 
eral causes. When the boy was first brought to rne, I at once investigated 
the question of self-abuse, or genital irritation, and obtained a negative 
result ; the Organs were found healthy, and the boy repeatedly declared his 
freedom from the evil habit referred to. It then occurred to me that the 
attacks of melancholia might be the result of slight or unobserved epilepti- 
form seizures; and, to elucidate this question, I caused Agie's parents to watch 
him closely, and made strict inquiries into his past life. As seen in the his- 
tory of the case, only once was anything observed which might pass for a fit, 
on February 7, 1875, when he "fainted dead away," and his father, an unre- 
liable witness, thought that he twitched. Against the epileptiform nature of 
the disease we have, furthermore, the failure of treatment by the compound 
bromide solution given in large doses from the beginning of February to the 
end of April. When, during the month of February, I learned of the injury 
to the head, it occurred to me that a morbid state of the meninges under the 
injured bone might be the cause of the symptoms. I accordingly performed 
an operation, and kept a sore running for weeks, at the seat of injury, but 
without relief. I was not prepared to advise trephining until a further trial 
of medicines had been made. The opium treatment appears to have had the 
best effect, when conjoined with cod-liver oil and other tonics. The approx- 
imate success obtained during the last six months by these means would point 
to mal-nutrition of the brain, as a cause of the melancholia: a pathological 
state not rare in the melancholia of adults.* 

Another case which has been treated at the clinic, and with greater suc- 
cess than the preceding, is that of Mary L., a married woman, aged 25 years, 
brought here August 29, 1874. "Has been married about four years, and 
lias borne two children, nursing them both. About two and a half years ago, 
after the birth of the first child, she experienced a choking sensation in her 
throat; felt as if she wanted to cry. This disappeared after a while, but re- 
appeared after the birth of the second child, a few months ago, the attacks 
of choking being preceded by a sense of cold in soles of feet and at wrists, 
accompanied by nausea, and by desire to weep. Is low-spirited and imagines 
that she is going to be sick, or that some disaster is to happen. Has nursed 
child constantly and freely, and has besides had sexual intercourse very often. 
Is thin, pale, and weak. Facies very despondent, patient is convinced that 
she cannot get well. Confesses that for many weeks she has had fearful im- 
pulses, to go and drown herself in the river, and to kill her children. The 
latter impulse surges up frequently within her, and she has had to fight hard 
to resist it. She has made it a rule to lock up all knives or other sharp in- 
struments in her rooms; and lately has, by her express wish, been closely 
watched by a woman in the day, and by her husband in the evening. Denies 
most positively having had any hallucination of sight or hearing. Has been 
careless of her home, of her dress, and person ; has lost interest in everything ; 
is extremely depressed, and often weeps. Reasons well upon all matters which 
usually are talked of by a woman in her station of life. Remembers every- 

* In a few months after the publication of this lecture, Agie was quite cured, 
found employment, and has remained well. — [E. C. S.] 



TREATMENT OF MELANCHOLIA AT HOME. 659 

thing well. Is inert, and indisposed to take any exercise. Often very wake- 
ful at night. 

I recognized this as a case of melancholia without delusions, but with 
strong morbid impulses. There had also been an hysterical element in the 
case. The causes of the exhaustion of physical and mental vigor were evi- 
dently prolonged lactation and too great sexual indulgence. I at once began 
a treatment based upon this view of the pathogeny of the case, enforcing 
weaning of the child, separation of the husband and wife at night, and or- 
dered food and tonics. She was given ale at night, meat and other nutri- 
tious food thrice a day ; was made to walk every day. In order to secure 
sleep, I prescribed a pill containing .03 of extract of cannabis indica and .015 
of powdered opium, to be taken three or four times a day, according to the 
effect produced. The patient was in the habit of rising at night to answer 
any cry of her infant child, and this was prevented by having a woman 
take entire charge of the child. At all times Mrs. L. was to be under guard 
to aid her in resisting the impulses described above. She was to stay a part 
of the day in her husband's store, and do what little she could to help him. 
Her husband and friends were strictly enjoined to do or svlj nothing tending 
to dejDress her or excite her emotions. I told the patient in the most positive 
terms that she would recover in a few weeks, and reiterated this assurance 
at every visit, though she often shook her head and said it was no use. 
Cod-liver oil was added to the treatment in October, and the number of opium 
and cannabis pills was reduced, at first, to two a day, later to one at bed- 
time. On October 5th, I gave her, after meals, a pill containing extract of 
nux vomica .015, zinc phosphide .01 gm. and zinc oxide .0G. This was 
discontinued on October 23d, and a mixture substituted, each drachm dose 
of which contained .003 of strychnia, and 2. of Horsford's acid phosphates, 
with 2. of syrup of orange flowers. At first, Mrs. L. took three doses ; later, 
in November, four doses a day, continuing the cod-liver oil and ale. The last 
prescription which I wrote for this patient was on November 24th, 1874, when 
I gave her. 30 of pyrophosphate of iron three times a day. At that time 
she was perfectly well. The improvement had appeared very soon after 
the patient began to rest at night and ceased exhausting herself. She gained 
flesh and color rapidly, and, pari passu with the physical gain, came a mental 
improvement, greater tranquillity of mind, a little hope of recovery, interest 
in matters of every-day life, and ability to banish every thought of injuring 
others. I urged the patient to exert her volition to the utmost, when such 
ideas arose in her mind, and to seek relief from them also in occupation. 
Corresponding with these changes in the bodily and moral state of the patient, 
a degree of healthy coquetry made its appearance, as shown in the arrange- 
ment of hair and dress. 

A case, similar in many respects to * the above, occurred in my private 
practice during the past autumn. 

Mrs. Lev., aged 27, came to my office, September 22d, 1875. She had 
been married six years, and had had four children in that time, not nursing 
any of the children, and not having any complications in labor. Last con- 
finement occurred in January last, and after it she was not well ; her children 
were sick, and she obtained but little sleep for four months. Had pain at 



660 TREATMENT OF MELANCHOLIA AT HOME. 

top of head and in left side of abdomen, nausea, and pain at the pit of the 
stomach. A physician in Mobile made an examination and found the uterus 
' ' ulcerated. " Was frequently purged, and received local treatment, with 
relief to nausea, pain in the head and abdomen. She, however, grew weak 
under this treatment. In the last few months, chief symptoms have been 
mental and moral; the patient has become despondent, wished for solitude, 
expressed her inability to do anything, and her conviction that she is crazy 
and will not recover. Her sleep has been unrefreshing, and she has not 
seemed to gain any strength from food. Lately, the negative mental state 
has become very pronounced, and patient must be urged to rise, to dress, to 
eat, to go out. She is apprehensive of softening of the brain, etc., and states 
that her head feels dull and stopped up ; she feels childish, foolish, and irritable. 
Shakes her head incredulously when I tell her that she is sure to get well. 
The memory is a little impaired for recent events ; there is no incoherency 
in speech ; no delusion ; and patient denies having had any hallucinations. 
She is conscious of the feebleness of her will, and of the torpid, helpless state 
in which she is. Complains of no pain, but has at times creeping sensa- 
tions over the whole body; sometimes is a little dizzy, and has a feeling of 
pressure at the back of the head. Has a tender point in mid-dorsal region, 
and before treatment of uterine disease had one in the lumbar spine. The 
menses have appeared irregularly at five or eight weeks' interval, have been 
copious, and have caused weakness. There are now no symptoms of uterine 
disease. The fundus of the eye is normal ; the face pale, and the patient's 
eyes underscored with black. She has become emaciated, and is compara- 
tively weak. This patient often said that she had rather die than be in the 
state she was, but never had any strong suicidal impulse, and never any de- 
sire to injure any one. The prominent psychological state was the negative 
condition, in which she found herself without reaction to the usual stimuli of 
life. She said that she could not rise in the morning, could not dress, could 
not take medicine, could not walkout. "I aui worse than a child," was 
her oft-repeated complaint. I made the diagnosis of physical prostration and 
melancholia sine delirio, and encouraged her friends to believe that she 
was to recover in a few months. Toward the patient I adopted a more posi- 
tive tone, and told her that she would get well surely, positively ; and that 
before Christmas she would be a healthy woman. This statement I repeated 
as a part of the treatment at every interview. 

I prescribed a moral and a medicinal treatment. In the first place I in- 
structed the friends of Mrs. Lev. to watch her constantly, because, though 
there was no tendency to suicide then present, such a disposition might be 
suddenly developed and an attempt made to gratify it. The patient was to 
be aided by the will of others in all things ; she was to be made to rise at a 
certain hour, if necessary, by the stern means of taking away her bed-covers. 
She was to be helped and expedited in the operation of dressing, and 
brought down-stairs in time to breakfast with the family. The same punctu- 
ality was to be enforced in other things. Kegularly, also, she was to be 
taken out walking, twice a day at least ; and, after a while, when better, I 
directed that she was to be obliged to take care of her room. Now, gentle- 
men, this was not tyranny, as one unacquainted with the subject might think, 



TREATMENT OF MELANCHOLIA AT HOME. ' 661 

but a kind assistance to the patient. She was glad that the will of others 
was interposed to help her out of the negative state into which she had 
drifted. Of course, in carrying out this plan, no physical violence was to 
be used. I told the friends to throw the odium of enforcing disagreeable 
things upon my shoulders, by saying: "The doctor says it must be done." — 
"You promised the doctor that you would do it," etc. I furthermore en- 
joined them never to deceive the patient in order to make her do anything or 
to gain her good-will. This means is one which I believe should very seldom 
be resorted to, in mild cases of insanity. In addition, Mrs. Lev. was to be 
amused moderately, invited to play cards or backgammon, and later, when 
stronger, was to be taken to matinees at the theatres. 

In the second place, I ordered the following medicinal treatment : The 
patient to go to bed at 10 o'clock, after drinking the better part of a bottle of 
porter. Her three meals were to be substantial; meats, eggs, etc. With her 
dinner she was to take a pint bottle of porter. Cod-liver oil was pre- 
scribed in doses of 4. after each, meal to be slowly increased to 15. ; and I 
gave .001 of phosphorus, in the shape of 2. of Thompson's alcoholic solu- 
tion, thrice a day. The galvanic current was applied to the head a few 
times, with the effect, apparently, of relieving the dysesthesia of which she 
complained. October 5th. — Not much improved in mental condition; it is 
difficult to enforce rules of life prescribed ; patient still very obstinate and 
quite hopeless. The cod-liver oil and phosphorus are given together in an 
emulsion, according to the following formula : 

3. Vitelli ovor, 

01. morrhua?, SS, 120. 

Vini xerici, 60. 

Sol. phosph. (Thompson's), 

Syrup, simpl., S3, 15. 

Aq. amygdal. amar., 120. 
S. 30. after each meal. 

On October 11th there was added to the treatment a pill of cannabis and 
opium, .02 each, to be taken at bed-time with the porter. October 29th. — 
Great improvement, physical and mental ; patient begins to believe that she 
will recover ; shows more spontaneity ; she shows disgust for the emulsion of 
phosphorus and oil, and is ordered Caswell's oil with hypophosphites of lime 
and soda, 8., after meals, to be increased. Porter, twice a day, as before; 
opium and cannabis at bed-time. In the early part of December, Mrs. Lev. 
was very much better, almost herself in fact. I directed that the opium and 
cannabis pills, and the cod-liver oil be no longer given, and prescribed the 
following tonic and stimulating pills : 

3. Ext. cannabis, 0.20. 

Ferri sulph., exsiccat., 

Sodas carbonat. aa, 8. 
M. 

In capsul. no. xxx., divid. 
S. Two after each meal. 



662 TREATMENT OF MELANCHOLIA AT HOME. 

By Christmas-time recovery was quite complete. The patient became 
anxious to go back home, to care for her house and children, and was only 
prevented from going by being led to expect her husband from week to 
week. Until his arrival, in February, 1876, Mrs. Lev. amused herself much, 
and though not taking medicine, observed the hygienic and dietetic rules I 
had laid down for her guidance. Her husband's arrival was the occasion of a 
severe test of her recovery, and he was obliged to tell her that, during the 
early winter, one of her children had died. This news, gently imparted, 
provoked an outburst of passionate sorrow, but no relapse. 

Another case in my private practice, illustrating the points I wish to lay 
before you, was that of Mr. M., aged 28 years, married, and a wine merchant 
by occupation. He had been a healthy and temperate man, whose business, 
though prosperous, had pressed heavily upon him. From being a travelling 
salesman, he had become partner, and he felt the responsibility acutely. 

During the winter of 1873-74, marked physical fatigue and slight chronic 
lowness of spirits manifested themselves. In February, 1874, Mr. M. slept 
less well, waking about early dawn and tossing uneasily about until the hour 
of rising. In March lie became more depressed, ceased taking part in social 
games, needed spurring about everything, and began to speak of the bad way 
his business was in, and hinted at approaching ruin and beggary. In point 
of fact, this was the beginning of a delusion, as his affairs were in a fairly 
prosperous state. In April, after taking quinia pills, he began to speak about 
a stoppage in his bowels, and frequently remarked that he ought to die. 

When I first saw Mr. M., in April, 1874, he was sitting in a chair, wearing 
a most melancholy expression, in strange contrast with his ruddy cheeks and 
general appearance of good health. He only half rose to greet me, and gave 
me a lifeless hand. He was in good flesh, his pulse strong, and not above 80. 
His tongue was much coated and his breath very foul. His frame of mind was 
that of despair, yet he was not emotional. ' ' You can't do anything for me, 
doctor," he said. "My bowels are stopped and nothing will go through me; 
I shall choke with all the food they force me to take ; my business is wholly 
ruined; we are beggars now; I can't go to business, I can't exert myself." 
He would put his hand on his abdomen and say, in the most despairing way : 
"There it is, doctor; you can't put anything through me." He had been 
sleeping less and less well of late, in spite of bromide of potassium which had 
been given him by a friend, in considerable doses, for weeks. No hallucina- 
tions. 

I made the diagnosis of melancholia with delusions, and informed the wife 
that success in treatment at home depended upon her vigilance and our suc- 
cess in overcoming his objection to food. In case he positively refused to eat, 
I should be in favor of his immediate transfer to an institution. 

I administered croton-oil pills, broken up in tea, with the result of giving 
him many free movements ; but the sight of the evacuations and our argu- 
ments did not dispel the delusion that his bowels were stopped up. He con- 
tinued for weeks to entertain this notion, and to protest against being fed. 
He was like many insane persons, reasoning correctly upon a false premise- 
I was fearful that he might draw from his other belief, viz. : that he and his 
were beggars, the conclusion that it would be desirable and proper to kill his 



TREATMENT OF MELANCHOLIA AT HOME. 663 

wife or himself. Consequently I enjoined upon his wife to remove from the 
room anything which might serve as an instrument of injury, to have the 
windows nailed fast, and to watch him incessantly. I directed that nutritious 
liquid food be given to him frequently ; beef tea, chicken broth, milk punch 
and egg-nog. In reality, he was supported chiefly upon milk and brandy, 
taking as much as eight and ten ounces of the latter per diem for two weeks 
and more ; when, as he began to eat more, "the amount was lessened. The 
bromide of potassium was discontinued, and I prescribed chloral to be given 
in case the stimulant did not make him sleep. I believe that few, if any, 
doses of chloral were necessary. As a tonic, and with the view of counter- 
acting the depressing effects of the bromide of potassium which had been 
taken during so many weeks (no eruption produced), he was ordered: 

$. Strychnia?, 0.06. 

Acid. phos. dil., 30. 

Syr. aurant. cort., 90. 
M. 
S. A teaspoonful three times a day. 

Fortunately Mr. M. , although protesting against being given food, which 
must accumulate and choke him, yet remained good-natured, and made no 
physical opposition when his wife fed him and told him that it was the doctor's 
positive orders that he must eat. After a fortnight the refusal became less strong 
and gradually disappeared. He was taken out to walk once or twice a day. 
helped in dressing himself, and, when better, made to go down into the parlor 
and see friends. He often, during April and May, assured me that I would 
never be paid, as he was a beggar, etc. After the 1st of June, the patient 
rapidly improved, sleeping and eating well, and using much less stimulant. 
On June 13th I substituted for the strychnia mixture the following ; 

~B,. Ext. nucis vom., 0.60. 

Pulvis rhei, 

Ext. cannabis, Sff, 1. 

Quiniae sulph., 2. 
M. 

In pil., no. xxx., divid. 
S. One before each meal. 

About the middle of June, Mr. M. went to his father's place on Long 
Island, his wife accompanying him and watching him without his being aware 
of it. He w r orked about the house, bathed in the surf (never alone), and 
steadily improved. During the early part of July he referred to the locked 
state of his bowels for the last time. The last wrong notion to disappear w T as 
that about his business. In September and October he was well, only he 
feared to go to business because of mortified pride. He was afraid of remarks 
about his having been crazy. He had no more delusions, but his will was 
very feeble (it had never been strong), and it needed all his wife's exhorta- 
tions and my own words of cheer to induce him to start life anew. He re- 
membered all that had taken place, and was ashamed. v 



664: TREATMENT OF MELANCHOLIA AT HOME. 

In these four cases, gentlemen, we find the chief symptoms 
of the melancholic state, or the condition of depression. 

A. Psychic pain. — This element, difficult to define, was pres- 
ent in all the cases. It was indicated by words, and, better still, 
by the expression of the face, and the attitude of the body. The 
patient feels low-spirited, is without hope, the world appears as 
if a black pall had been thrown over it, friends are careless or 
have become enemies, everything goes wrong. This condition of 
the mind is one with which nearly all of us are acquainted in a 
milder degree, constituting what is popularly known as a "fit of 
the blues." In many persons the "blues" amount to a short 
attack of melancholia with positive delusions, lasting one or two 
days. Satisfaction with the past, contentment with the present, 
and hope for the future, as well as all energy and power of en- 
joyment vanish when the fit begins. And, I believe, from the 
experience of my friends, and from my own, that such attacks of 
transient melancholia are often the result of overwork or of 
mental strain. Some individuals will have such a fit quite 
surely after a month or two of hard professional work, just as 
another will close such a period by an attack of sick-headache. 
A day of desperate brooding succeeded by a night of unusually 
good sleep, brings the attack to a close, and the subject awakes 
brighter and more energetic than he was for days before the 
storm ; again, just as occurs after a sick-headache. 

B. The negative state. — Whether from absorption in his 
mental wretchedness, or because of the influence of dominating 
or terrifying delusions, the patient shows no spontaneity in ac- 
tion ; he fails to react normally (often does not react at all) to 
external stimuli or to the incitations which may arise within 
him as results of preserved intellection. A mode of expression 
of this negative state is the unwillingness of the patient to act, 
and his liking to sit or stand still in one position for minutes, or 
hours, or days. Many melancholic patients (while still preserv- 
ing reasoning capacity) will never rise from the bed, or dress, or 
eat, or walk, unless made to do so by an impulse from without. 
This negative state was present in Cases I., III., and IV., and 
faintly developed in Case II. 

C. Impairment of volition. — This was more or less marked 
in all the cases. In Case II., the patient, while unable to over- 
come her depression and inertia, was yet able to control the 
frightful impulses to murder her children. Yet she felt that 



TREATMENT OF MELANCHOLIA AT HOME. 665 

her feeble volition was not to be depended upon, and took the 
precautions to have some one with her all the time, and to lock 
up all cutting instruments. No one could say when the im- 
pulses might become irresistible. In many subjects, volition 
seems to be utterly absent (or unused) for positive purposes, for 
inciting to externally manifest acts, but appears excessively 
developed in a negative or opposing way, as in refusing food or 
objecting to taking exercise. In mild cases, no such obstinacy 
exists, and patients yield to positive commands with greater or 
less readiness. 

1). Morbid impulses. — These were, I think, present in all 
the cases. The young lad whose case I first related was led by 
these impulses to do many disagreeable things, whistling, crow- 
ing, stamping, kicking, etc. He was never aggressive or wicked, 
never stole or attempted to set fire to anything. Yet, I take it, 
that he was a subject well-disposed to insane thieving or incen- 
diarism (technically known as kleptomania and pyromania). In 
Case II., the impulses were constant and copious, and they were 
of a murderous type, tending to cause homicide. The patient's 
depressed mind was agonized by the dread that she might fail 
to resist the impulse. Suicide might logically have resulted 
from this condition, the patient having reasoning power left to 
prefer killing herself to injuring her children. In Cases III. and 
IV., the morbid impulses were weak or concealed. 

E. Hallucinations. — We understand by hallucination the oc- 
currence of a false sensorial impression. The boy thought he 
saw thieves in a room, but there were none to see. A patient 
will hear voices when there are none sounding, or will smell 
odors when no one else can perceive them. Another patient 
will declare that certain sensations occur inside of him or upon 
his skin, when a careful examination shows no reason for believ- 
ing that any such sensations can exist. I would remind you 
that a person can have hallucinations of any of the senses, and 
yet not be insane ; the difference in this respect between the sane 
and the insane being that the mentally healthy mind cor- 
rects the false impression by the exercise of reasoning, or by 
means of tests applied by the other senses. For example, a 
person having an hallucination of sight (seeing an animal or a 
man) will make sure by touch or by reasoning that no one 
is there. Again, one who has lost a limb by amputation, 
may have an hallucination of the sense of touch, leading him 



666 TREATMENT OF MELANCHOLIA AT HOME. 

to believe that the amputated part is still attached, but he 
corrects the error at once, even though the impression be very 
vivid. The insane, on the contrary, accept an impression as 
true, and the hallucination then constitutes a delusion. Physio- 
logically, a hallucination is to be looked upon as an outward 
projection of a deep-seated sensation or irritation of the 
special centres for sight, etc., projected outward into the ex- 
ternal world as images, etc. I might take this opportunity of 
remarking that prolonged and vivid hallucinations of hearing in 
the insane make the prognosis more unfavorable. 

F. Delusions. — In my spring lectures upon insanity, I have 
proposed to classify delusions into sensorial and notional ; or, 
into those which consist in a firm belief in unreal objects, or 
sensations (connected with hallucination), and those which con- 
sist in a belief in unfounded ideas. For example, in case I. the 
patient believed that thieves were in the room, and had a sen- 
sorial delusion which no amount of reasoning could dispel. In 
Cases III. and IY., the false beliefs were psychologically differ- 
ent : in the one case, the patient believed that she could not 
recover, and in the second, that he was ruined and that his fam- 
ily were beggared. Or, a subject will, in melancholia, believe 
that he is damned, or, in general paralysis, that he is the father 
of fifty thousand children, eighteen thousand of whom are black, 
as in a case observed by my friend, Dr. Chas. Langdon, in the 
Hudson River State Hospital. In seme cases, it may be difficult 
to draw the line between sensorial and notional delusions, on 
the one hand, and between notional delusions and eccentricity 
or peculiar belief, on the other hand. 

G. Preservation of the mind, or of the memory and the 
power of reasoning, exists, in most cases of melancholia which 
are to get well. — In our cases, this preservation was almost com- 
plete ; in only one case — Case III. — is diminution of memory 
noted. In all the cases, however, the reasoning powers were 
torpid, or appeared so, because of the difficulty of observing 
their operation. It is common, however, for persons recovered 
from insanity to tell us that they had full use of their powers of 
observation and reasoning during their illness, but could not 
make this activity externally apparent. A knowledge of this 
condition will guide you in your relations with insane patients, 
leading you to use great kindness (though combined with firm- 
ness) and honesty toward them. I would have you know that a 



TREATMENT OF MELANCHOLIA AT HOME. 667 

harsh word, a blow, a trick, or a satirical remark, will be remem- 
bered by nine patients out of ten. 

I have occupied so much time in speaking of psychological 
symptoms that I cannot add much about the physical ones ; 
they are sufficiently detailed in the histories of the cases, and 
bespeak prostration of the nervous system, anaemia, and es- 
pecially mal-nutrition of the brain. 

As regards the importance of anaemia, as a pathological fac- 
tor, in these and analogous cases, I would say that it is often 
overrated and wrongly stated. That the general anaemia (span- 
aemia) should lead to impairment in the nutrition of all tissues, 
and of the brain in particular, I admit, with every one. But that 
chronic diminution in the quantity of the whole mass of blood 
shall lead to the development of melancholia in a direct manner 
(i. e. f by producing ischaemia of the brain) I consider extremely 
doubtful. In other words, I hold that rarely, if ever, is chronic 
anaemia a factor of as great importance as mal-nutrition of 
the anatomical elements of the brain ; a mal-nutrition which 
may occur while the organ is receiving a normal quantity of 
normal blood, being brought about in such a case by excessive 
activity (waste) of the anatomical elements. I entertain analo- 
gous objections to the generally received idea that congestion is 
frequently a leading pathological factor in cerebral diseases, and 
furnishes the chief indication for medication. 

The aetiology of the cases is worth recapitulating, as in it we 
find indications for treatment. The first case I would separate 
in this connection, because it is anomalous in its manifestations, 
and probably many causes (paternal vice, insufficient food, and 
possibly the action of over-heat) co-operated to bring about the 
morbid state. Besides, I would not, even now, after months of 
observation, positively deny the epileptic origin of the oft-recur- 
ring attacks. 

In Cases II. and III., types of a very numerous class, long-con- 
tinued drain both upon nerve power and upon the nutritive 
fluids (too frequent child-bearing, lactation, and excessive sexual 
indulgence) was the cause. In very many cases, the numerous 
factors (insufficient food and clothing, alcoholic and sexual ex- 
cesses, thwarted desires, oppression, anxiety for daily bread, 
etc.), which go to make up the condition briefly called " mis- 
ery " in the lower classes, come into play. In Case IV. we 
see the operation of a moral cause (so-called) upon a healthy 
though rather feeble-minded individual. He could not stand 



668 TREATMENT OF MELANCHOLIA AT HOME. 

the advancement and prosperity which his industry and faithful- 
ness in a subordinate position had brought to him. Anxiety, of 
a purely imaginary kind, overpowered him. 

Now, gentlemen, about the management and treatment of 
such cases. After you have made a diagnosis in a case of insan- 
ity, the first question which will come up for consideration be- 
tween you and the family of the patient will be the momentous 
one : Shall the patient be treated at home, or shall he be sent to 
an asylum for the insane ? As upon the decision of this ques- 
tion may depend not only the life and reason of the patient, but 
also the existence of persons around him and the preservation 
of property, I think it worth while to give you all the aid in my 
power to lead you to a right decision. In the first place, be 
prepared for a protest on the part of the family against removal, 
and assertions that they will never consent to it, that it would 
kill the patient, etc., and do not let your judgment be influenced 
by such clamor ; the question is one not be decided by consid- 
erations of sympathy and affection,' but by reason and the light 
of experience. Three chief points should be studied in this con- 
nection ; 1st. Are the hallucinations, delusions, and impulses of 
the patient vivid and strong? 2d. How obstinate is his- refusal 
of food ? 3d. How distinct is the tendency to suicide ? I am 
speaking only of cases of melancholia, please remember. 

If hallucinations and delusions are strongly marked, the 
other two states will most probably also be largely developed. 
The refusal of food, when positive, obliges us to feed patients by 
means of the stomach tube — a procedure almost impossible in 
private practice — as the operation should only be done by a 
medical man. If the suicidal tendency is strongly developed (if 
the patient fancies, for example, that a celestial voice bids him kill 
himself to avoid damnation), the watching at home will not be suf- 
ficient to prevent the accomplishment of the wish. Patients will 
wait months for an opportunity to throw themselves out of the 
window, or to drown themselves. My rule is in such a state to 
declare that the patient must be placed in an asylum, or that I 
can have nothing further to do with the case. I can hardly con- 
ceive of arrangements which could induce me to take charge of 
a severe case of melancholia confined in a private house (except 
in the late, incurable stage in which dementia is present). 
Another reason for advising the removal of the patient to an 
asylum, or separating him from his relatives, is when he con- 
nects most of his melancholic delusions with the members of the 



TREATMENT OF MELANCHOLIA AT HOME. 669 

family, or when their presence appears to plunge him in the 
slough of despair and psychic pain. Besides the considerations 
named above, there is one which has great weight with the rela- 
tives of patients, viz. : that the chances of recovery are much 
increased by an early removal to an asylum. 

If the symptoms enumerated above are not strongly marked — ■ 
if, in other words, the case is one of mild melancholia — you may, 
I think, properly undertake to treat it at home. 

By what means? In the first place, by kind, firm, and 
judicious management as described in the cases related in the 
first part of the lecture. Instruct the relatives and nurses to 
watch incessantly, to prevent the accomplishment of a concealed 
plan of suicide. I would have you feel that every depressed 
patient may commit self-destruction. The minutiae of this watch- 
ing and care I cannot enter into ; they will readily occur to you. 
Secure a cheerful moral atmosphere for the patient as far as 
possible ; make him eat, go to walk, engage in simple games, 
pay some attention to social duties. Tou may use an authorita- 
tive tone and manner toward him without failing to be kind and 
considerate. Let your positiveness be his helpful stay ; let your 
will replace his own which is so feeble. 

Many such patients will need "building up," which means 
the giving of a more nutritious food in larger quantities, to- 
gether with the extra foods, alcohol and oil. This "building 
up " would, of course, be in vain, if you did uot look after every 
possible source of drain upon vitality, lactation, menorrhagia, 
uterine disease, repeated child-bearing, sexual excesses, legiti- 
mate and solitary, and put a stop to the one you find active. 

As aids to improve nutrition and strength you have a choice 
among many tonic medicines, including some of the class " re- 
storatives " of Headland, such as hypophosphite of lime and soda, 
free phosphorus,* iron, manganese, arsenic, strychnia, alcohol. 

*Free phosphorus may be given in ethereal, alcoholic, or oily solution. One 
of the best (and my favorite) modes is by Thompson's solution of phosphorus 
{The Practitioner, 1873, II., p. 13, p. 271), the formula for which is as follows: 

Phosphorus, gr. 0.40. 
Absolute alcohol, 120. 
Dissolve and add : 
Glycerin, 270. 
Alcohol, 15. 
Mix the two solutions and, while hot, add essence of peppermint 15. 
4. of this solution contains nearly .002 of phosphorus. 
It may be given as it is, or with more glycerin, or with cod-liver oil. 



670 TREATMENT OF MELANCHOLIA AT HOME. 

In order to produce sleep, I would advise you to use either 
chloral or opium. The bromide of potassium is generally pre- 
scribed, but without much good effect. We do not know that it 
is a direct hypnotic, and the quietude which its continued (days 
or weeks) use brings about, is accompanied, I am convinced, by 
mal-nutrition of the cerebral tissue. Thus, while it may for a 
time do apparent good by preventing restlessness, it injures the 
patient by perpetuating a condition of the brain which we 
believe to be fundamental in the melancholic state. The use of 
chloral, if not too long continued, is better, and less injurious. 
"We can produce quiet certainly by this drug, and most patients 
can take it long without showing symptoms of chloral poisoning. 

Opium, cannabis indica, and alcohol often make melancholic 
patients sleep Very well ; and, besides, they improve the nutri- 
tion of the brain, render the circulation in it more active, and 
thus expedite cure. These drugs belong to the classes narcotics 
and deliriants of Headland : they first, when given in proper 
doses, produce intoxication, and then depression and sleep. To 
all of the patients, about whom I have talked to you, I gave 
alcohol, in some shape or other — porter, milk-punch, etc. All 
but one took opium and cannabis. These medicines I give in 
pillular form, pushing the opium up to the point of slight nar- 
cosis (which is difficult to produce in these cases), and seldom 
giving more than .10 cannabis in the twenty-four hours. Or, as 
has been practiced lately in France, with great success, 
morphia may be given hypodermically twice a day in gradually 
increasing doses. This plan, in private practice, is open to the 
objection that the physician must make too frequent visits. 

Galvanization of the spinal cord, and of the cervical sympa- 
thetic, has been used in Europe and in this country, in the treat- 
ment of melancholia, with apparent success. It is important to 
apply the current continuously (i. e., without shocks), in order 
to obtain a good effect. For particulars of the methods recom- 
mended, I refer you to Althaus, Medical Electricity, London, 
1873, p. 483. 

There are many other points in the treatment of mild cases 
of melancholia at home, which I have not time to dwell upon, 
such as the regulation of the action of the bowels, sponging with 
cold water, x>r the use of cold compresses, the choice and grada- 
tion of occupation and amusement each day, etc. Your com- 
mon sense and medical knowledge, together with a knowledge 



TREATMENT OF MELANCHOLIA AT HOME. 671 

of the patient's habits, will guide you safely in these matters. I 
have the greatest faith in the efficacy of amusement and employ- 
ment in the treatment of insanity in general, and of melancholia 
more particularly. Reading aloud to the patient, inducing him 
to play some simple games, backgammon, dominoes, croquet, 
billiards, taking him to places of interest, and, when convales- 
cent, to minstrels or theatre. All these things will be of service. 
For women, knitting, sewing, the care of a room, will be proper 
occupations at home. There comes a time, in convalescence, 
when travel is a most valuable remedial means, involving, as it 
does, change of climate, variety of food, exercise, j^leasant sights, 
and association with strangers. In the moral treatment we must 
aim to displace the painful, depressing ideas which surge in the 
patient's mind, and try to break up the chain of association be- 
tween morbid physical conditions and unhealthy mental states. 

I would close by warning you that you will need to exercise 
much patience in the successful management of such cases, that 
you should make the family understand that the treatment will 
last months, and that, if you are not faithfully and actively 
aided by the patient's friends or by nurses in the carrying out 
the moral treatment, your medication will prove quite useless. 



THE CULTIVATION OF SPECIALTIES IN MEDICINE.* 

Or the many practical questions which present themselves to 
the minds of students of medicine, and even more forcibly to the 
minds of young graduates, few, I take it, are more interesting 
than the one : " Shall I practice medicine in general, or become 
a specialist? " 

The importance of this question seems to warrant my making 
it the text of remarks on this occasion, when the Faculty of the 
College have delegated to me the pleasing duty of bidding you 
welcome. 

The growth of specialism in medicine is quite modern, I might 
say recent, yet its germ is ancient. For example, in the cele- 
brated medical school of Alexandria, and among Arab or Saracen 
physicians in the first six hundred years of our era, we find men- 
tioned as special practitioners, surgeons, lithotomists, oculists, 
and midwives. On the other hand, I doubt not but that more 
than one of the venerable pillars of our alma mater, the senior 
professors who are with us this evening, clearly recall the time 
when there were no specialists in the United States ; a time 
when all practitioners of medicine, somewhat arbitrarily divided 
into the classes of physicians and surgeons, knew all there was 
to be known of medical science, and successfully enough prac- 
ticed in a corresponding general way. Then no one devoted all 
his energies to the critical study of changes in the human cuticle, 
or spent hours peering into eyes with a little mirror, and rack- 
ing his brains over complicated mathematical formulae to correct 
nature's failure to produce a perfect eye. No one made it his 
exclusive business to light up, expose, and more or less barba- 
rously medicate the various cavities and recesses of the human 
body, and no one (worst of all, I have heard it said) gave up all 
practice except that in connection with the nervous system. 
Were those the better days ? 

In the last thirty years all this has changed. Quite an army 

--"Address introductory to the session of 1880-81, at the College of Physicians 
and Surgeons, New York ; delivered October 1, 1880. Reprinted from the Ar- 
chives of Medicine, vol. iv. No. 3, December, 1880. 



TEE CULTIVATION OF SPECIALTIES IN MEDICINE. 673 

of specialists has sprung up all oyer the world; one specialty 
after another has made formal demands for recognition in the 
midst of the profession, and in the faculties of medical schools. 
Indeed, the human body has been so parcelled out to suit the 
demands of study and practice by specialists and pseudo-special- 
ists that there is probably no room to spare ; and the general 
practitioner is seemingly justified in exclaiming : " Would these 
specialist neighbors of mine leave me nothing to do ? " 

I repeat that specialties and specialists have increased re- 
markably in the last few years, and, planting themselves in large 
cities, have demanded the exclusive control of such cases of dis- 
ease as seemed to fall within the limits of their respective 
branches of practice, and at the same time claiming (often 
wrongly, I am sure) superior knowledge of such matters. 

This rapid growth, the rather loud claims, and the apparent 
great pecuniary success of specialists, have, naturally enough, 
roused in the ranks of the profession at large some adverse 
criticism and opposition. It has become rather fashionable, I 
suspect, to conveniently ignore the successful diagnosis and 
practice of specialists, and to pick out and hold up in full view 
their mistakes and failures. Yet, gentlemen, I appear before 
you to-night, prepared tp maintain that the growth of specialties 
has been, and is, of the greatest utility to medical science and to 
the welfare of the public ; and, also, that the practice of a spe- 
cialty is, under certain conditions, perfectly right. 

The growth of specialties is justifiable on the ground of its 
having been a natural and an almost inevitable development. 

No ambitious or ingenious physician planned the creation of 
a special practice, but specialties have slowly risen up in accord- 
ance, with the demands of the age; an age of unparalleled ac- 
cumulation of human knowledge and of wonderful fertility in 
means for the application of such knowledge to practical uses. 
In this general proposition are included a number of immediate 
causes of the growth of specialties, and some of these I purpose 
briefly to review. 

1. Early in this century, a considerable number of physicians 
in Europe, seem to have realized that a life-time of study would 
barely be sufficient to enable them to become conversant with 
the enlarging mass of medical knowledge, and that such an uni- 
versal knowledge, if attained, would not be thorough enough to 
fit them for universal practice. Besides, the time consumed and 
43 



674 THE CULTIVATION OF SPECIALTIES IN MEDICINE. 

the mental energy employed in this general study were incom- 
patible with original research and progress. 

Probably because of such ideas, together with the prompting 
of progressive genius, we find that certain members of our pro- 
fession, without becoming special practitioners, began and car- 
ried out special studies, and in several instances these special 
studies have made their authors immortal. 

For example, let me name Lsennec, in what we call physical 
diagnosis ; Bright and Rayer, in diseases of the kidneys ; Bayle 
and Esquirol, in so-called mental diseases ; Abercrombie and 
Ollivier, in diseases of the brain and spinal cord; Hope and 
Bouillaud in affections of the heart ; Cruveilhier, in pathological 
anatomy ; John Hunter, Bichat, Magendie and Muller in anat- 
omy and physiology. 

Each of these great men for years devoted almost all his en- 
ergy to the cultivation of what then seemed the outlying fields 
and dark by-ways of the domain of medical science. Had their 
ambition been, on the contrary, to be walking encyclopedias of 
medical knowledge, what would we say of them to-day? 

2. It is very probable that the methods of thought and man- 
ner of work of medical men in the first third of this century were 
considerably influenced by the development of specialties in 
general science. 

In previous times a few great men in each century had ap- 
peared with a master-knowledge of the whole of the science of 
their day. Such, for example, were Bacon, Linnaeus, Buffon, 
and, to a certain extent, Swedenborg. The birth of the natural 
sciences in the troubled times of the latter part of the eighteenth 
century may be looked upon as a sort of revolt against this as- 
sumption of universal wisdom by a few, and the beginning of 
independent, divergent, special work by the many. . 

If we take up this movement in the first half of our century 
we see, as examples, chemists busy for years at different branches 
of their science ; some searching by analysis for elementary 
bodies, or for alkaloids in plants ; others attempting the synthesis 
of substances ; others yet endeavoring to discover chemical prod- 
ucts which can be immediately useful in the arts, etc. We note 
the development of zoology into a great tree of knowledge whose 
various branches, — comparative anatomy, ornithology, ichthy- 
ology, entomology, paleontology and anthropology, — engage 
the attention — the special attention — of innumerable observ- 



THE CULTIVATION OF SPECIALTIES IX MEDICIXE. 675 

ers. Histology, animal and vegetable, has arisen as a separate 
science; and so has embryology. In other departments we see 

men devoting themselves for years or for a life-time to the study 
of light, of electricity, of nebulae and stars, of climate and 
weather, etc. 

To close this enumeration, let us say that the great scientific 
progress of the last fifty years has been the result, in greater 
part, of specialized research. And in the same period the men 
who, having a vast store of knowledge, have attempted to gen- 
eralize the labors of specialists are exceedingly few. Perhaps I 
do not exaggerate when I say that Charles Darwin is the only 
one whose efforts in this direction have been deemed deserving 
of universal acknowledgment. 

How could medical men, medical scientists, in constant inter- 
course with the promoters of general science, escape the tendency 
to specialize their studies? How could medicine, as a part of 
science, remain conservative and sluggish in those times of 
minute observation and analysis, of subdivision of intellectual 
work, and of hungry original investigation ? 

3. The unexpected ice afforded to medical research 

and practice by the progress of physics and the mechanical 
Xo more striking example of an influence of this sort can be 
adduced than the effect of the introduction of the ophthalmo- 
scope by Helmholtz in 1851. This instrument was not an acci- 
dental finding, but a truly scientific discovery resulting from the 
application of mathematics and physics to tte study of the human 
eye. From this period dates the formal appearance of the first 
specialty, viz., ophthalmology : a specialty which has attracted 
to its study many of the brightest minds of our profession, which 
has accumulated discoveries upon discoveries, and, partly owing 
to its being largely founded upon exact sciences, has carried 
diagnosis to a remarkable degree of accuracy, and brought its 
various therapeutic measures to a rare degree of perfection. 

The study of diseases of the cavities of the body, such as the 
nose, pharynx, larynx, and the more deeply placed organs has 
been greatly advanced by the invention of examining and illumi- 
nating apparatus. 

The microscope has no doubt facilitated the growth of manv 
a fine-spun and baseless theory, but it has certainly done much 
to enlarge the domain of science in the direction of physiology, 
diseases of the skin and kidneys, tumors, etc. At the present 



676 THE CULTIVATION OF SPECIALTIES IN MEDICINE. 

time, by its means important researches into the relation be- 
tween microscopic germs and diseases are being carried on by 
numerous competent observers. 

There are still other reasons, not perhaps scientific, why 
physicians have been led to limit their practice to certain 
branches. One is the great amount of time needed to carry out 
certain procedures of diagnosis and treatment, as for example in 
ophthalmic practice, in electro-therapeutics, hydro-therapeutics, 
etc. Again, in the last twenty-five years there has been a 
marked tendency to attempt the amelioration of chronic and so- 
called incurable diseases. These praiseworthy efforts need 
much thought and time, and can hardly be carried out by the 
busy general practitioner. Lastly, there is a strong popular 
demand for the services of specialists. Our patrons understand 
the advantages of concentrated study and large experience in 
limited fields of practice. The public seek special advice in the 
shape of consultations, or even place themselves in the hands of 
specialists for a time, without any disloyal intention toward 
their family physician, who is often a personal friend. 

Specialties, in study and in practice, have been, I believe, of 
advantage to medical science. 

By limiting their attention to specified branches of medicine, 
a considerable number of physicians have relieved themselves of 
the fatiguing cares and complex duties of general practice, and 
have thus obtained an amount of leisure time for study, and a 
tranquillity of mind favorable to original research. 

In this way they have been able to make a critical examina- 
tion of the writings of other observers in their own and in foreign 
lands, to make and record minute observations upon the living 
human being and upon the dead body, to undertake physiolog- 
ical experiments and anatomical researches intended to afford a 
logical basis for pathological hypotheses, and for an attempt at 
more rational therapy, and, finally, to accumulate experience in 
the comparatively rare diseases which general practitioners can 
only see at long intervals of time. 

The results of these special studies, in a variety of depart- 
ments, are beginning to take shape before us, as an unfinished 
yet a promising monument. 

Each specialty can now point with pride to the numerous 
discoveries made by its followers ; each can show a record of 
enthusiastic work, of keen discussions, of undoubted progress 



THE CULTIVATION OF SPECIALTIES IX JLEDICEXE. 677 

carried on or made public in its special organization or soci- 
ety. 

The literature of each, specialty lias grown to be immense ; 
embracing systematic works, pamphlets, and periodicals in many 
languages, and taxing to the utmost the industry of the special- 
ist who means to be well-read in his branch of medicine. In 
this connection, I might incidentally remark that a knowledge 
of the three great living languages is now almost a sine qua non 
of success in special study. 

The various specialties have, few will deny, proved useful to 
the public. I believe that multitudes of suffering human beings 
have been relieved or cured by specialists in the last thirty 
years, and that many, if not a majority, of these cases would not 
have been successfully treated by general practitioners, however 
learned and able they might have been. This proposition could 
be brilliantly supported from the records of ophthalmology, but 
every specialty can claim corresponding achievements. 

By limiting his range of practice, a physician in the course of 
a few years accumulates a large experience in the diagnosis, 
prognosis and therapy of certain diseases, many of which are 
looked upon as quasi-incurable, and are almost shunned by the 
general practitioner. 

Specialties are further useful to the public because they fur- 
nish peculiarly well qualified consulting physicians and surgeons. 
The willingness of general practitioners to seek special advice is 
becoming more and more evident. Even with our awkward rules 
of consultation, there need not be, I believe, any hostility or 
friction between the family physician and the specialist. The 
few unpleasant consultations of which I have been cognizant 
had been made so by personal faults in the physicians con- 
cerned. 

I would venture to suggest that, on the one hand, the spe- 
cialist who is saturated with tjie belief that he is the embodiment 
of science in his department, and who believes that the general 
practitioner cannot and does not know much in the same field, 
and, on the other hand, the general practitioner who is constitu- 
tionally unwilling or unable to have his diagnosis corrected or 
reversed, or to yield to the greater experience of the consulting 
physician — that both these men are equally ill-prepared for the 
delicate and important duties of consultation. 

To these favorable comments I am compelled to add a few 



678 THE CULTIVATION OF SPECIALTIES IN MEDICINE. 

words of warning respecting the intellectual dangers which I 
believe attend special practice. 

The first, or more evident, risk is that the specialist shall 
become a routine practitioner. This is, however, to a certain 
extent inevitable and justifiable. If, for example, a dermatolo- 
gist find that a certain ointment is perfectly successful in the 
treatment of some diseases, who shall blame him if he continue 
to prescribe the same ointment in similar conditions of the skin ? 
A given form of instrument is found best adapted to relieve a 
certain deformity or displacement : shall we apply the term rou- 
tine practitioner, in any opprobrious sense, to the orthopedist 
who applies this instrument one hundred or more times a year ? 

By no means. This is a necessary routine, a useful routine, 
and one which it would be unwise to break through for the sake 
of sham originality. 

But when such routine practice lulls a man asleep to the 
progress of his art, when it makes him blind and deaf to the im- 
provements of others, when it prevents him from experimenting 
and trying to find something better, something which shall cure 
more quickly or with less pain or annoyance, then routine be- 
comes a vice. Perhaps the mental state of the specialist who 
thus rests upon his oars, good oars though they be, might aptly 
be called one of partial dementia — a condition in which the past 
is remembered and overestimated, the living present is ignored, 
and the pregnant future unthought of. 

A second danger in special practice is the tendency to acquire 
a belief in the specific potency of drugs, as contra-distinguished 
from their use in accordance with indications furnished by the 
patient's actual condition. As examples, I may quote the indis- 
criminate use of quinia in periodical symptoms, or the now fash- 
ionable prescription of a bromide for insomnia, or the application 
of electricity for paralysis. Do we always pause to consider 
that some remarkably periodical symptoms are not malarial, 
but of nervous origin — that insomnia is merely a symptom, 
which may depend upon various pathological conditions, and 
which is sometimes more quickly relieved by stimulants than by 
sedatives — or that many cases of paralysis get well sponta- 
neously, or advance fatally, regardless of our electrical appa- 
ratus ? 

Closely attached to specific medication is the graver fault 
which I may term symptom-worship. Naturally enough, the 



THE CULTIYATIOX OF SPECIALTIES IX MEDICINE. 679 

specialist's attention is taken up with the very striking symptom 
which has caused the patient to consult him; such as convul- 
sions, headache, eczema, failing sight, aphonia, etc. Some phy- 
sicians, I fear, at once prescribe a favorite remedy or application 
in obedience to a half-avowed belief in specific medication. 
Others give more time to the case, analyze it somewhat, and 
prescribe intelligently. But how many have the courage to 
thoroughly investigate the problem, and then base their special 
practice in the case in hand upon the solid foundation of gener- 
al medical knowledge ? To do this consumes time, may call for 
delicate manipulations, and the acquired data must be submit- 
ted to a peculiar compound of inductive and deductive reason- 
ing, in order to form a clear conception or hypothesis of the 
symptoms presented by the patient, as explained by general 
physiological, pathological and etiological laws. 

Without such an inquiry, how can we hope to construct a 
rational treatment ? 

Allow me to repeat that symptom worship and specific pre- 
scribing must flourish in dne proportion to the i of gener- 
al pathology by spocialisS. This is the substance of one 
of the chief arguments against the usefulness of specialties. It 
is claimed that the specialist is necessarily one-sided; that he 
carries on his researches and his practice in a mole-like way, 
i. e., working in a furrow and ignoring its relations to the gener- 
al system of medicine. I think that such a charge is unjust 
when applied in a general way ; and I believe that, as years go 
on, fewer and fewer specialists will render themselves open to 
this serious accusation. 

Having discussed the origin, utility, and dangers of sp 
ties in medicine, there remain some practical deductions or 
advice to be addressed to you personally. 

You will recollect that at the opening of my address I said 
that one of the important questions which agitate the minds of 
students and young graduates in medicine is, whether to become 
specialists or not. 

Now, this question, like one or two others equally personal 
which will occupy your thoughts, I earnestly beg you not to be 
in any haste to decide. Pray do not, as the popular phrase is, 
"take up a specialty," for it seems to me .that few things can 
be more unfortunate than that a young man, whether student or 
graduate, should label himself a specialist in his own mind or in 
the world's eve. 



680 THE CULTIVATION OF SPECIALTIES IN MEDICINE. 

On the contrary, let your aim for several years be to cultivate 
your profession in a general way, with all the industry and the 
time which a providential lack of private patients will leave you 
This, I need hardly explain, is to be done by systematic read- 
ing and study, by hospital experience, and by the general prac- 
tice of your art. For, even if you are ultimately to become 
specialists, let me assure you that you cannot be too well 
grounded in general diagnosis, in general therapeutics, and in 
anatomical and physiological knowledge. 

During these years of preparatory study and work, not by 
any means unpleasant years to look back to, it may happen that 
you become greatly interested in some one branch of medicine, 
that circumstances lead you to see many diseases of a certain 
class ; and that you experience a real desire, an ambitious de- 
sire, to cultivate this specialty. Thus, and then, if surrounding 
social conditions are favorable, if your medical friends consider 
that you are wise in your choice, a career as a specialist is open 
to you. This is what I would call a physician's natural growth 
into specialism. 

In contra-distinction to the above rational process of first 
securing a thorough post-graduate medical education, and then 
carefully following one's intellectual bias in the choice of a spe- 
cial study or practice, I would hold up to you as a warning the 
course of those who, soon after graduating, with or without resi- 
dence in a hospital, say to themselves, Let us be specialists — 
oculists, dermatologists, gynecologists, or what not. A certain 
fashion seems to determine which of the specialties is to be 
" taken up " by these hasty wooers. Some years ago ophthal- 
mology was the proper thing ; later still neurology was sought 
after ; now I suspect (one can't be quite sure of contemporary 
movements) that gynecology is popular. I believe that such a 
course is a great evil for those who adopt it, for the unfortunate 
patients who fall in the hands of these pseudo-specialists, and 
finally harmful for the scientific reputation of other men who 
properly cultivate the special fields of medicine. 

I have heard it whispered, pretty loud too, that some young 
men proclaim themselves specialists or "take up a specialty" 
under the delusion that a special practice is easy and very re- 
munerative. Now, I am not disposed to deny that some few 
specialists are in the end handsomely rewarded ; but who, save 
these favored few, realize what patient waiting, and what long- 



THE CULTIVATION OF SPECIALTIES IN MEDICINE. 681 

continued labor are implied by this success ? Then, how many 
would-be specialists toil and wait, yet never come to be recognized 
as such by their confreres and by the public ? There must be a 
mingling of remorse with great disappointment after having thus 
spent years in an artificial attempt to be a specialist without 
reward. 

Yet, I do not wish to be understood as maintaining that the 
honest and well-prepared student of a specialty must succeed. 
Xo, gentlemen, there is no Sunday-school, good-boy doctrine in 
such real-life questions. The artificial, ill-grounded, relatively 
ignorant special practitioner may make money and even attain a 
certain distinction, while his neighbor, who has carefully and 
conscientiously worked his way along so as to be looked upon 
with respect by his associates, and even quoted as an authority, 
may fall short of success. This is because there enters into the 
problem of success in the practice of medicine a personal or 
social element of great importance, and which studious, original, 
and independent men are very apt to ignore. The successful 
physician is nearly always something more than learned : he is 
personally agreeable to his patients. 

Finally, in considering whether you are to be specialists or 
not, I would have you bear in mind the normal organization of 
the great professional body whkjh you join on graduating. 

The immense majority of our brethren are settled in the 
country, in small villages and small cities, and they of necessity 
must be general practitioners. All honor to these men, forty 
thousand of them, I presume, who labor day and night, to the 
best of their ability and knowledge, for the relief of their neigh- 
bors' ailments. "We can see them, with the help of our imagina- 
tion, floundering through snow storms in the North, plodding 
along on horseback in the scorching sun-heat of the South, vent- 
uring into malarious regions, treating and even nursing con- 
tagious diseases, missing their meals — in fact, often shortening 
their lives to prescribe for the sick at rates of remuneration 
which we in New York consider ridiculously small. What 
matter if these men do not know all the fine points in medical 
science, if they have never heard of the depressor nerve, or do 
not know the name of the laryngeal muscles, or if they cannot 
establish the minute distinctions between various spinal paraly- 
ses ? What if several times in their lives of usefulness, placed 
face to face with an unique or a complicated case, without the 



682 THE CULTIVATION OF SPECIALTIES IN MEDICINE. 

help of special counsel, they do too little or even do wrong? 
Will any one regret it more than they ? And again, who, even in 
the elect circles of medical centres, does not also fail sometimes ? 

This great mass of the profession in the country and in cities, 
of which the majority of you must ultimately form a part, I 
greatly respect, all the more because I am the grandson of a 
physician who, for more than sixty years, was a useful and re- 
spected general practitioner in town and country. 

Evidently, only a few physicians can, in obedience to the law 
of supply and demand, be specialists ; and these few are found 
grouped according to certain geographical circumstances. No 
one would venture to attempt special practice in a village or in 
a large town. Even in cities of from fifty to one hundred thou- 
sand souls there is barely a living for one specialist in each 
department. Usually, special cases in such thinly populated 
regions are treated by one whom I may call, with no intended 
disrespect, the quasi-specialist. He is a general practitioner 
who has devoted time and pains to acquiring special knowledge 
and skill in the treatment of certain diseases. Other physicians 
are glad to send special practice to such a medical man if he be 
well qualified and honest in his professional relations ; yet there 
may not be enough of such work to warrant his relinquishing 
general practice. Even in large cities there are many excellent 
physicians who might likewise be classed as quasi-specialists, 
yet I cannot but suspect that their special practice is dwindling 
as the public acquire more liking for strictly special advice and 
care. 

There is, besides, a rather unclassified sort of physician in 
large cities, who is, to parody Moliere, a specialist malgre lui ; 
or, if you prefer it, a specialist nolens volens. This highly respect- 
able gentleman usually expresses contempt for specialists ; he 
looks upon them as narrow-minded, half-blind men working in a 
rut. He himself is widely read in medical lore, he may be a 
sort of walking encyclopedia, and he has practiced in all ways. 
Yet, fortunately for the public, though perhaps unfortunately 
for his grand ideal, this physician is known to his colleagues by 
his systematic work on this, or his lectures on that, or his mono- 
graphs on various topics, etc. He is de facto a specialist ; his 
confreres and people generally know that his opinion is particu- 
larly valuable in certain affections, and his consultation practice 
is colored accordingly. If he be a professor or a writer, his 



THE CULTIVATION OF SPECIALTIES IN MEDICINE. 683 

lectures and books reveal what really is in him in spite of a show 
of universal wisdom ; and the bulk of what he writes is common- 
place alongside of that part which treats of the topics he has 
unconsciously specialized. 

Lastly, in all large cities there are the pure or strict special- 
ists, that is, physicians who decline all practice outside of their 
specialty. I greatly hope to see this small class somewhat en- 
larged, mainly for the reason that we would then have a larger 
number of well-qualified observers with leisure to work, and 
thus a marked impetus would be given to original medical re- 
search in this country. 

In this address I have endeavored to show that the growth 
of specialties has been normal, and in accord with the general 
scientific movement of the age ; that specialties are useful to the 
public and to medical science ; and that the practice of a spe- 
cialty is not unattended by intellectual dangers. 

I have neither urged you to become specialists nor advised 
you to shun and contemn specialties ; but have tried to make 
plain and forcible my opinion, that the decision to become a 
specialist should be reached deliberately, upon a careful esti- 
mate of the tendencies and capabilities of your minds ; and that 
your special studies and practice should rest upon a broad and 
solid medical culture. 

Very few of you can expect to become strict specialists, and 
the career of all the rest as quasi-specialists and general prac- 
titioners will be equally useful, equally desirable socially, and 
equally honorable. 



INDEX. 



Abscess following injections of cuinine, 

Abscess of left frontal lobe of cerebrum, 

452 
Abuse and use of bromides, 226 
Aconitia in the treatment of trigeminal 

neuralgia, 367 
Aconitia, doses and formula. 368 

do. in posterior spinal sclerosis. 402 
Actual cautery, use of in medicine. 393 
Acute central myelitis, case of, 
do. ocular oedema, case of. 56 
do. poliomyelitis in children. 84 
Alkaline water as a vehicle for bromide 

of potassium, etc.. 539 
Aneurism of the cceliac axi-. 
Aphasia, history and pathology of. 37 
Arsenical myelitis, 616 
Arterial supply of the brain, 
Ataxia, progressive locomotor. 

do. as a symptom 
Autopsies in infantile paralysis, 95 

Basal meningitis in children, 251 
Basis cerebri, lesions of, 318 
Birdsall's foot-dynamometer, 560 

Bromide of potassium in hay-asthma, 

241 
Bromide of potassium in epilepsy, 234 
Bromides, their abuse and use. 226 
Bromism, 228 
Bulbar paralysis, case of, 249 

Cancer of vertebra? and paraplegia. 612 
Cannabis indica for migraine. 242 
Cautery, mode of application, 398 

do. " forms of, 393. 
Cerebellum, diseases of, 335 
Cerebral localizations, contributions to, 

27, 202. 337, 407. 452. 495, 609, 

647 
Cerebral syphilis, a clinical lecture. 276 
Cervical paraplegia, clinical studv of. 

253 
Cervical sympathetic nerve, in a case of 

unilateral sweating of the head. 72 
Cervico-braehial neuralgia and aneurism 

of the innominate artery, case of. 

636 
Coincidence of optic neuritis and sub- 
acute transverse myelitis. 421 



Contracture in hemiplegia, physiology 
of, 132, 451 

Cortex cerebri, physiology of. 337 
do. do. lesions ot, 337 

Cortical centres. 341 

Cranio-cerebral topography. 318. 647 

Cultivation of specialties in medicine, 
672 

Cutaneous lesion from bromide of potas- 
sium. 629 

Deformities in infantile paralysis 
Dermatitis produced by opium. 

do. produced by bromide of po- 
sram, 629 

Description of a peculiar paraplcgifonn 
affection, 127 

aamation of the kidneys during the 
administration of mercury and iodide 
of potassium, 1C3 
Piagnosis of progressive locomotor atax- 
ia. 353 
Diagnosis of some organic diseases of the 

"nervous system. 437 
Diagnosis of paralytic dementia. -164 
do. of tumor of the brain. 4<»7 
do. methods of, 558 
Diagrams for cranio-cerebral topographv, 

648, 640, 651 
Diagram of motor cortical centres, 573 

do. of spinal areas, 436 
Diphtheritic ataxia, case of. 493 
Disseminated cerebro - spinal sclerosis, 

ca-es of. 264 
Dosage of fluid extract of conium, 596 
do. of aconitia, 599 
do. of phosphorus, 602 
do. of nitrate of silver, 605 
do. of bromides, 235 
Double central canal of spinal cord, 74 

Early diagnosis of organic nervous dis- 
eases, 457 
Early recognition of epilepsy. 540 
Efficient dosage of certain remedies used 
in the treatment of nervous diseases, 
594 
Ependyma, granulations of, 67 
Epilepsy, treatment by bromides. 234 

do. * importance of its early diag- 
i nosis, 540 

685 



686 



IXDEX. 



Epileptic and eclamptic attacks, 550 
Excision of brachial plexus for neural- 
gia, 97 

Folie a deux, 405 

Formulas of bromide solutions, 235 
Frontal lobe, abscess of, 4o2 
Fulgurating pains, 355, 4Z8, 463 

General paresis of the insane, case of, 

76 
Glycosuria, cases of, 644 
Granulations of cerebral ventricles 67 

Headache and choked disc with tumor of 

the brain, 609 
Hemianopsia, physiology of, 325 

do. diagram of, 327 
Hemiplegia, beginning in the foot, case 
of, 407 
do. spinal, case of. 57 
Hemorrhagic pachymeningitis, case of, 

416 
Hyoscyamia as an hypnotic, 472 
do. in insanity, 477 
do. as a depresso-motor, 484 
do. paralysis agitans, 485 
Hyoscyamia, formula for hypodermic 

use, 486 
Hyoscyamia, in chorea, 488 
Hypodermic injection of quinine, 22 
Hysterical hemi-amesthesia in a male 

subject, 641 
Hysterical symptoms in organic nervous 
affections, 180 

Infantile spinal paralysis, 84 
Inhibitory arrest of the act of sneezing, 

118 
Injury to motor area of the brain, case 

of, 608 
Insanity, contagion of, 405 
Internal capsule, lesions of, 333 
Intra-buccal method of faradizing the 

facial muscles, 419 
Iodide of potassium in non-syphilitic 

organic nervous diseases, 579 

Lectures on the localization of spinal 
and cerebral diseases, 283 

Localization of spinal and cerebral dis- 
eases, lectures on, 283 

Localization of diseases of the spinal 
cord. 486 

Localized lesions of the cortex cerebri, 
407 

Localized basal meningitis in children, 
251 

Localized cerebral lesions, first contribu- 
tion, 202 ; second contribution, 494 

Malarial fevers, treated by subcutaneous 
use of quinine, 15 



1 Mania, autopsy of case, 62 

Medulla oblongata, lesions of, 316 
do. do. structure of, 311 

Medicinal treatment of chronic trigem- 
inal neuralgia, 375 

Melancholia, its treatment at home, Goo 

Mercury and iodide of potassium, ef- 
fects on kidneys, 403 

Metallo-therapy,-case of. 641 

Methods of diagnosis in nervous dis- 
eases, 558 

Migraine, its treatment bv Indian hemp, 

Movable kidneys, case of, 415 
Myelitis with optic neuritis, 421 

do. following acute arsenical poi- 
soning, 616 
Mysophobia, case of, 429 

Neuralgia, treatment by subcutaneous 

use of quinine, 10 
Neuritis, pathological anatomy of, 106 
do. of traumatic origin, 401 

Occipital headache as a symptom of 
uraemia, 432 

Opium, eruptions from, 380 
Optic neuritis and myelitis, 421 
Outline of the physiology of the nervous 
system, 164/ 

Pachymeningitis, cases of, 195 
Paraplegia in syphilitic subjects, 413 
Pathology of infantile paralysis, 90 
Pedal neuralgia, traumatic, 401 
Physiology of the nervous system, 164 
Pneumonia, temperature of, 1 
Poliomyelitis, after injury, 381 

do. infantile. 84 

Post-paralvtic chorea, clinical study of, 

197 
Pyramidal decussation, 312, 450 

Quinine subcutaneouslyin malarial neu- 
ralgia, 10 
do. in malarial fevers, 15 

Simulated glycosuria, 645 

Slow pulse 'and epileptiform convul- 
sions, case of, 409 

Sneezing, historical and physiological 
considerations, 118 

Solution of quinine for hypodermic use, 
15 

Solution of hyoscyamia, 486 

Specialties in medicine, 672 

Speech, mechanism of, 33 

Spider cells in sclerosis, 270 

Spinal cord, localized diseases of, 436 
do. lesion of one-half of, 57 
do. focal lesions of, 304 

do. systematic lesions of, 293 

do. columns of, 289 



IXDEX. 



687 



Spinal hemiplegia, case of, 57 
do. physiology, 309 
do. paralysis in children, 84 
Statement of the aphasia question, 27 
Subcutaneous use of quinine in malarial 

neuralgia, 10 
Subcutaneous use of quinine in malarial 

fevers, 15 
Syphilitic paraplegia, 413 

Tabes dorsalis, differential diagnosis, 364 
Table of hysterical symptoms, 181 
Tetanoid paraplegia,' 127, 383 
Theory of cerebral contracture, 132 
Therapeutic contributions, 10, 15, 97, 

139, 226, 242, 256, 367, 375. 393, 401, 

419, 472, 484, 492, 529, 534, 579, 

594, 641, 655 
Therapeutics of the nervous system, 138 
Thermometer in clinical medicine, 1 
Tracings of slow pulse, 410 

" of paralysis agitans, 485 



Traumatic brachial neuralgia, case of. 

97 
Traumatic epilepsy, case of, 608 

do. pedal neuralgia, case of, 401 

do. poliomyelitis, case of, 381 
Trichinosis, case of, 55 
Trigeminal neuralgia, treatment of, 367. 

375, 534 
Treatment of cervical paraplegia, 256 

do. of migraine, 242 

do. of trigeminal neuralgia, 367 

Uraemia, with occipital headache. 432 
Ulcus elevatum from use of bromides. 
620 



Van der kolk's law in diagnosis. 574 
Vertebral cancer and paraplegia, case of. 
6:2 

Word-deafness, case of, 508 



